{ "hospital_name": "Resnick Neuropsychiatric Hospital at UCLA", "last_updated_on": "2025-03-29", "as_of_date": "2025-01-01", "version": "2.0.0", "hospital_location": [ "Resnick Neuropsychiatric Hospital at UCLA" ], "hospital_address": [ "150 UCLA Medical Plaza, Los Angeles, CA 90095" ], "license_information": { "license_number": "930000153|CA", "state": "CA" }, "affirmation": { "affirmation": "To the best of its knowledge and belief, the hospital has included all applicable standard charge information in accordance with the requirements of 45 CFR 180.50, and the information encoded is true, accurate, and complete as of the date indicated.", "confirm_affirmation": true }, "standard_charge_information": [{ "description": "0.9% SODIUM CHLORIDE--CONTROL FOR ATG", "drug_information": { "unit": "0.100000", "type": "UN" }, "code_information": [ { "code": "63323018610", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 1158.0, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.72, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ABACAVIR SULFATE 20 MG/ML PO SOLN", "drug_information": { "unit": "240.000000", "type": "UN" }, "code_information": [ { "code": "64980040524", "type": "NDC" } ], "standard_charges": [ { "minimum": 61.45, "maximum": 204.97, "gross_charge": 218.05, "discounted_cash": 119.93, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 126.47, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 119.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 174.44, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 184.69, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.45, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 104.66, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 130.61, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 130.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 204.97, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 191.88, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.45, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 185.34, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 163.54, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 76.82, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 148.27, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 204.97, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 170.73, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 119.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 173.35, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 163.54, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 191.88, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 126.47, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 119.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ABACAVIR SULFATE 300 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68084002121", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.55, "maximum": 8.51, "gross_charge": 9.05, "discounted_cash": 4.98, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.25, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.94, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.24, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.67, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.63, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.34, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.42, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.41, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.51, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.96, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.55, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.69, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.79, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.19, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.15, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.51, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.09, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.94, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.19, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.79, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.96, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.25, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.94, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ABACAVIR SULFATE-LAMIVUDINE 600-300 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "65862033530", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ABACAVIR-DOLUTEGRAVIR-LAMIVUD 600-50-300 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "49702023113", "type": "NDC" } ], "standard_charges": [ { "minimum": 119.51, "maximum": 398.65, "gross_charge": 424.1, "discounted_cash": 233.26, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 245.98, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 231.56, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 339.28, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 359.21, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 123.41, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 203.57, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 254.04, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 253.61, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 398.65, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 373.21, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 119.51, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 360.49, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 318.08, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 149.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 288.39, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 398.65, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 332.07, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 231.56, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 337.16, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 318.08, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 373.21, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 245.98, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 231.56, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ABATACEPT 125 MG/ML SC SOSY", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00003218811", "type": "NDC" } ], "standard_charges": [ { "minimum": 23.72, "maximum": 3636.54, "gross_charge": 3868.66, "discounted_cash": 2127.76, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2243.82, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.72, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3094.93, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3276.76, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1125.78, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1856.96, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2317.33, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2313.46, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3636.54, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3404.42, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1090.19, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3288.36, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2901.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1362.93, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2630.69, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3636.54, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3029.16, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.02, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3075.58, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2901.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3404.42, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2243.82, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.72, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "ABATACEPT 125 MG/ML SC SOSY|DISCARDED DRUG NOT ADMINISTERED", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00003218811_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 23.72, "maximum": 3636.54, "gross_charge": 3868.66, "discounted_cash": 2127.76, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2243.82, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.72, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3094.93, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3276.76, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1125.78, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1856.96, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2317.33, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2313.46, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3636.54, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3404.42, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1090.19, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3288.36, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2901.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1362.93, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2630.69, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3636.54, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3029.16, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.02, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3075.58, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2901.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3404.42, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2243.82, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.72, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "ABATACEPT 250 MG IV SOLR", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "00003218713", "type": "NDC" } ], "standard_charges": [ { "minimum": 23.72, "maximum": 3735.29, "gross_charge": 3973.71, "discounted_cash": 2185.54, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2304.75, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.72, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3178.97, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3365.73, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1156.35, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1907.38, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2380.25, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2376.28, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3735.29, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3496.86, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1119.79, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3377.65, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2980.28, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1399.94, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2702.12, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3735.29, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3111.41, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.02, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3159.1, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2980.28, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3496.86, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2304.75, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.72, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "Abd paracentesis", "code_information": [ { "code": "49082", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 691.08, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 511.91, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 67775.04, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 122978.9, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 691.08, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 122978.9, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Abd paracentesis w/imaging", "code_information": [ { "code": "49083", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 691.08, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 511.91, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 2041.54, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 3704.4, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 691.08, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 3704.4, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ABIRATERONE ACETATE 250 MG PO TABS", "drug_information": { "unit": "4.000000", "type": "UN" }, "code_information": [ { "code": "60687079021", "type": "NDC" } ], "standard_charges": [ { "minimum": 6.58, "maximum": 21.96, "gross_charge": 23.36, "discounted_cash": 12.85, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.55, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.75, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.69, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.79, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.8, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.21, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.99, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.97, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.96, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.56, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.58, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.86, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.52, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.23, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.88, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.96, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.29, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.75, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.57, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.52, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.56, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.55, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.75, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Ablate bone tumor(s) perq", "code_information": [ { "code": "20982", "type": "HCPCS" }, { "code": "20983", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 9484.13, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 7025.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3900.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 33418.51, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 60638.42, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 9484.13, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5265.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 60638.42, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Ablate inf turbinate submuc", "code_information": [ { "code": "30802", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1091.85, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 808.78, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 15415.22, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 28328.7, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1091.85, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 28328.7, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Ablate inf turbinate superf", "code_information": [ { "code": "30801", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1091.85, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 808.78, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 14226.88, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 25814.89, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1091.85, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 25814.89, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Ablate pulm tumor perq crybl", "code_information": [ { "code": "32994", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 7674.11, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5684.53, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 13502.61, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 24500.7, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7674.11, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 24500.7, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Ablate pulm tumor perq rf", "code_information": [ { "code": "32998", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4300.51, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3185.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 14866.73, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 26975.92, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4300.51, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 26975.92, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Abltj mal prst8 tiss hifu", "code_information": [ { "code": "55880", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 6816.07, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5048.94, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 14238.67, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 25836.3, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6816.07, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 25836.3, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Abltj perc plex/trncl nrv", "code_information": [ { "code": "0442T", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4720.44, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3496.62, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 10044.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 18225.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4720.44, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 18225.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ABOBOTULINUMTOXINA 300 UNITS IM SOLR", "drug_information": { "unit": "300.000000", "type": "UN" }, "code_information": [ { "code": "15054053006", "type": "NDC" } ], "standard_charges": [ { "minimum": 4.71, "maximum": 1938.28, "gross_charge": 2062.0, "discounted_cash": 1134.1, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1195.96, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.71, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1649.6, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1746.51, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 600.04, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 989.76, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1235.14, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 1233.08, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1938.28, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1814.56, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 581.07, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1752.7, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1546.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 726.44, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1402.16, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1938.28, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1614.55, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.36, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1639.29, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1546.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1814.56, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1195.96, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.71, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "ABOBOTULINUMTOXINA 500 UNITS IM SOLR", "drug_information": { "unit": "500.000000", "type": "UN" }, "code_information": [ { "code": "15054050001", "type": "NDC" } ], "standard_charges": [ { "minimum": 4.71, "maximum": 3229.84, "gross_charge": 3436.0, "discounted_cash": 1889.8, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1992.88, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.71, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2748.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2910.29, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 999.88, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1649.28, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2058.16, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2054.73, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3229.84, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3023.68, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 968.26, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2920.6, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2577.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1210.5, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2336.48, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3229.84, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2690.39, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.36, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2731.62, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2577.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3023.68, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1992.88, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.71, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "Abortion", "code_information": [ { "code": "59841", "type": "HCPCS" }, { "code": "59840", "type": "HCPCS" }, { "code": "59850", "type": "HCPCS" }, { "code": "59851", "type": "HCPCS" }, { "code": "59855", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2343.63, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1736.02, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 5932.49, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 10764.6, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2343.63, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 10764.6, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Abortion (mpr)", "code_information": [ { "code": "59866", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 224.22, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 166.09, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 5523.46, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 10022.4, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 224.22, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 10022.4, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ABSORBABLE HEMOSTAT", "drug_information": { "unit": "5.000000", "type": "GR" }, "code_information": [ { "code": "82526100005", "type": "NDC" } ], "standard_charges": [ { "minimum": 156.92, "maximum": 1158.0, "gross_charge": 556.85, "discounted_cash": 306.27, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 322.97, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 304.04, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 483.35, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 162.04, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 267.29, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 333.55, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 333.0, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 523.44, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 490.03, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 156.92, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 473.32, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 417.64, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 196.18, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 378.66, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 523.44, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 436.01, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 304.04, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 442.7, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 417.64, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 490.03, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 322.97, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 304.04, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ABSORBASE EX OINT", "drug_information": { "unit": "454.000000", "type": "GR" }, "code_information": [ { "code": "46287050716", "type": "NDC" } ], "standard_charges": [ { "minimum": 14.49, "maximum": 48.34, "gross_charge": 51.43, "discounted_cash": 28.29, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.83, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.08, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.14, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.56, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.97, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.69, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.81, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.76, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 48.34, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.26, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.49, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.72, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.57, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.12, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.97, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 48.34, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.27, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.08, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.89, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.57, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.26, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.83, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.08, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Access thoracic lymph duct", "code_information": [ { "code": "38794", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 40598.97, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 73667.49, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 73667.49, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ACD FORMULA A 0.73-2.45-2.2 GM/100ML VI SOLN", "drug_information": { "unit": "750.000000", "type": "UN" }, "code_information": [ { "code": "14537081775", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 1158.0, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", 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billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, 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}, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ACD FORMULA A 0.73-2.45-2.2 GM/100ML VI SOLN (PEDS CRRT PRISMAFLEX)", "drug_information": { "unit": "750.000000", "type": "UN" }, "code_information": [ { "code": "14537081775_5", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 1158.0, "gross_charge": 40.0, "discounted_cash": 22.0, 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"additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ACETAMINOPHEN 10 MG/ML 0-50 ML SYRINGE", "drug_information": { "unit": "100.000000", "type": "UN" }, "code_information": [ { "code": "00264410090_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ACETAMINOPHEN 10 MG/ML 0-50 ML SYRINGE (2 DAY MAX DURATION)", "drug_information": { "unit": "100.000000", "type": "UN" }, "code_information": [ { "code": "00264410090_3", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ACETAMINOPHEN 10 MG/ML 50-100 ML INTRAVIA", "drug_information": { "unit": "100.000000", "type": "UN" }, "code_information": [ { "code": "00264410090_4", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ACETAMINOPHEN 10 MG/ML 50-100 ML INTRAVIA (2 DAY MAX DURATION)", "drug_information": { "unit": "100.000000", "type": "UN" }, "code_information": [ { "code": "00264410090_5", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ACETAMINOPHEN 10 MG/ML IV SOLN", "drug_information": { "unit": "100.000000", "type": "UN" }, "code_information": [ { "code": "00264410090_6", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ACETAMINOPHEN 10 MG/ML IV SOLN (2 DAY MAX DURATION)", "drug_information": { "unit": "100.000000", "type": "UN" }, "code_information": [ { "code": "00264410090_7", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ACETAMINOPHEN 10 MG/ML SYRINGE (NICU)", "drug_information": { "unit": "100.000000", "type": "UN" }, "code_information": [ { "code": "00264410090", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ACETAMINOPHEN 120 MG RE SUPP", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "51672211502", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ACETAMINOPHEN 32 MG/ML PO LIQUID", "drug_information": { "unit": "2.500000", "type": "UN" }, "code_information": [ { "code": "68094013058", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ACETAMINOPHEN 325 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "50580045811", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ACETAMINOPHEN 325 MG RE SUPP", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "51672211602", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ACETAMINOPHEN 500 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00904673061", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ACETAMINOPHEN 650 MG RE SUPP", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "45802073032", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": 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88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ACETAMINOPHEN 80 MG PO CHEW", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00904579146", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ACETAMINOPHEN-CODEINE 120-12 MG/5ML PO SOLN", "drug_information": { "unit": "15.000000", "type": "UN" }, "code_information": [ { "code": "1785607901", "type": "NDC" } ], "standard_charges": [ { "minimum": 3.72, "maximum": 12.42, "gross_charge": 13.21, "discounted_cash": 7.27, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.66, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.21, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.57, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.19, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.84, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.34, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.91, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.9, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.42, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.62, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.72, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.23, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.91, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.65, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.98, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.42, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.34, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.21, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.5, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.91, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.62, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.66, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.21, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ACETAMINOPHEN-CODEINE 300-30 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00406048462", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.25, "maximum": 7.52, "gross_charge": 8.0, "discounted_cash": 4.4, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.4, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.78, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.33, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.84, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.79, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.25, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.8, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.82, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.44, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.26, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.36, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ACETAMINOPHEN-CODEINE 300-60 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "1310706001", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.25, "maximum": 7.52, "gross_charge": 8.0, "discounted_cash": 4.4, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.4, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.78, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.33, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.84, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All 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charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.8, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.82, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.44, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.26, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.36, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ACETAZOLAMIDE 100 MG/ML SYRINGE(PEDS)", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "09992019007", "type": "NDC" } ], "standard_charges": [ { "minimum": 36.45, "maximum": 121.57, "gross_charge": 129.33, "discounted_cash": 71.13, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.01, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 70.61, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.46, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 109.54, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 62.08, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 77.47, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 77.34, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 121.57, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 113.81, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.45, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 109.93, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 97.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.56, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.94, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 121.57, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 101.27, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 70.61, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 102.82, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 97.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 113.81, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.01, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 70.61, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ACETAZOLAMIDE 250 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "50268005415", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.2, "maximum": 4.0, "gross_charge": 4.26, "discounted_cash": 2.34, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.47, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.33, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.41, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.61, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.24, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.04, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.55, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.55, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.75, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.2, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.62, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.5, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.9, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.34, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.33, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.75, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.47, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.33, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ACETAZOLAMIDE 25MG/ML ORAL SUSPENSION", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "P5167240231", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.14, "maximum": 3.82, "gross_charge": 4.06, "discounted_cash": 2.23, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.35, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.25, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.44, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.18, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.95, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.43, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.43, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.82, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.57, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.14, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.45, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.05, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.43, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.76, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.82, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.23, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.05, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.57, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.35, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ACETAZOLAMIDE ER 500 MG PO CP12", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687057821", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.14, "maximum": 7.15, "gross_charge": 7.61, "discounted_cash": 4.19, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.41, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.16, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.09, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.45, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.21, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.65, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.56, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.55, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.15, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.7, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.14, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.47, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.71, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.68, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.17, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.15, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.96, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.16, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.05, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.71, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.7, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.41, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.16, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ACETAZOLAMIDE SODIUM 500 MG IJ SOLR", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "39822019001", "type": "NDC" } ], "standard_charges": [ { "minimum": 18.67, "maximum": 62.28, "gross_charge": 66.25, "discounted_cash": 36.44, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.43, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.17, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 53.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 56.11, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.28, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.68, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.62, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 62.28, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 58.3, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.67, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 56.31, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.69, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.34, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.05, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 62.28, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 51.87, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.17, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.67, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.69, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 58.3, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.43, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.17, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ACETIC ACID 0.25 % IR SOLN", "drug_information": { "unit": "1000.000000", "type": "UN" }, "code_information": [ { "code": "00338065604", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 1158.0, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.72, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ACETIC ACID 2 % OT SOLN", "drug_information": { "unit": "15.000000", "type": "UN" }, "code_information": [ { "code": "52817081615", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.56, "maximum": 38.57, "gross_charge": 41.03, "discounted_cash": 22.57, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.4, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.82, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.75, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.94, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.69, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.58, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.54, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.57, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.11, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.56, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.77, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.45, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.9, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.57, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.4, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.62, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.77, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.11, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.4, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ACETIC ACID 3 % SOLN", "drug_information": { "unit": "30.000000", "type": "UN" }, "code_information": [ { "code": "P8252005130", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 1158.0, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.47, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ACETIC ACID 5% SOLN", "drug_information": { "unit": "60.000000", "type": "UN" }, "code_information": [ { "code": "P4444075330", "type": "NDC" }, { "code": "P4444075360", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 1158.0, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.47, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ACETYLCHOLINE CHLORIDE 20 MG IO SOLR", "drug_information": { "unit": "0.500000", "type": "UN" }, "code_information": [ { "code": "24208053920", "type": "NDC" } ], "standard_charges": [ { "minimum": 20.52, "maximum": 1158.0, "gross_charge": 72.82, "discounted_cash": 40.05, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.24, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.76, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.21, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.19, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.95, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.62, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.55, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 68.45, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 64.08, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.52, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.9, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.62, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.65, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.52, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 68.45, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 57.02, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.76, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 57.89, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.62, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 64.08, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.24, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.76, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ACETYLCHOLINE INTRACORONARY SYRINGE", "drug_information": { "unit": "12.000000", "type": "UN" }, "code_information": [ { "code": "09991000125", "type": "NDC" } ], "standard_charges": [ { "minimum": 73.79, "maximum": 1158.0, "gross_charge": 261.85, "discounted_cash": 144.02, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 151.87, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 142.97, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 227.29, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 76.2, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 125.69, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 156.85, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 156.59, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 246.14, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 230.43, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 73.79, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 222.57, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 196.39, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 92.25, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 178.06, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 246.14, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 205.03, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 142.97, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 208.17, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 196.39, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 230.43, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 151.87, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 142.97, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ACETYLCYSTEINE 20 % IN SOLN", "drug_information": { "unit": "3.000000", "type": "UN" }, "code_information": [ { "code": "00517760425_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.63, "maximum": 8.78, "gross_charge": 9.34, "discounted_cash": 5.14, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.42, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.1, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.47, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.91, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.48, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.59, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.59, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.78, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.22, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.63, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.94, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.01, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.29, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.35, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.78, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.31, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.1, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.43, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.01, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.22, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.42, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.1, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ACETYLCYSTEINE 20 % IN SOLN (INHALATION)", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00517760425", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ACETYLCYSTEINE 200 MG/ML IV SOLN", "drug_information": { "unit": "30.000000", "type": "UN" }, "code_information": [ { "code": "72611086004", "type": "NDC" } ], "standard_charges": [ { "minimum": 23.61, "maximum": 78.75, "gross_charge": 83.78, "discounted_cash": 46.08, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 48.59, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.74, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 67.02, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 70.96, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.38, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.21, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.18, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.1, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 78.75, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 73.73, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.61, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 71.21, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 62.84, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.52, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 56.97, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 78.75, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.6, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.74, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 66.61, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 62.84, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 73.73, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 48.59, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.74, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ACETYLCYSTEINE OPHTHALMIC SOLN 20%", "drug_information": { "unit": "12.000000", "type": "UN" }, "code_information": [ { "code": "08252000247", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 1158.0, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 95.48, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ACITRETIN 10 MG PO CAPS", "drug_information": { "unit": "3.000000", "type": "UN" }, "code_information": [ { "code": "42794008008", "type": "NDC" } ], "standard_charges": [ { "minimum": 47.78, "maximum": 159.39, "gross_charge": 169.56, "discounted_cash": 93.26, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 98.34, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 92.58, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 135.65, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 143.62, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.34, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 81.39, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 101.57, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 101.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 159.39, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 149.21, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.78, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 144.13, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 127.17, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.74, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 115.3, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 159.39, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 132.77, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 92.58, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 134.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 127.17, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 149.21, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 98.34, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 92.58, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ACITRETIN 25 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "42794008308", "type": "NDC" } ], "standard_charges": [ { "minimum": 19.63, "maximum": 65.49, "gross_charge": 69.67, "discounted_cash": 38.32, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.41, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.04, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.74, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.01, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.27, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.44, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.73, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.66, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.49, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.31, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.63, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.22, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.25, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.54, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.38, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.49, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.55, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.04, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.39, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.25, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.31, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.41, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.04, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ACTIDOSE WITH SORBITOL 25 GM/120ML PO SUSP", "drug_information": { "unit": "120.000000", "type": "UN" }, "code_information": [ { "code": "66689020304", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.32, "maximum": 37.77, "gross_charge": 40.18, "discounted_cash": 22.1, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.3, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.94, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.14, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.03, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.69, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.29, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.07, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.03, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.77, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.36, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.32, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.15, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.14, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.16, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.32, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.77, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.46, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.94, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.94, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.14, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.36, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.3, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.94, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ACYCLOVIR 200 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00904578961", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ACYCLOVIR 200 MG/5ML PO SUSP", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "2315548551", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ACYCLOVIR 400 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "50268006115", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ACYCLOVIR 5 % EX OINT", "drug_information": { "unit": "15.000000", "type": "GR" }, "code_information": [ { "code": "72578008201", "type": "NDC" } ], "standard_charges": [ { "minimum": 10.13, "maximum": 33.79, "gross_charge": 35.95, "discounted_cash": 19.77, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.85, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.63, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.76, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.45, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.46, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.26, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.53, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.5, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.79, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.64, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.56, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.96, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.67, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.45, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.79, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.15, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.63, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.58, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.96, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.64, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.85, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.63, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ACYCLOVIR 800 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68084010901", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ACYCLOVIR SODIUM 50 MG/ML IV SOLN", "drug_information": { "unit": "20.000000", "type": "UN" }, "code_information": [ { "code": "55150015520", "type": "NDC" } ], "standard_charges": [ { "minimum": 13.4, "maximum": 44.7, "gross_charge": 47.55, "discounted_cash": 26.15, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.58, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.96, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.04, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.27, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.84, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.82, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.48, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.43, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 44.7, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.84, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.4, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.42, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.66, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.33, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 44.7, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.23, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.96, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.66, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.84, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.58, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.96, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ADALIMUMAB 20 MG/0.2ML SC PSKT", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00074061602", "type": "NDC" } ], "standard_charges": [ { 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{ "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2736.78, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4514.27, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5633.43, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 5624.03, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8840.45, "standard_charge_percentage": 94.0, "methodology": 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"standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 6626.59, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 12790.47, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 17680.94, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 14727.85, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": 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billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 10269.99, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ADALIMUMAB-ATTO 40 MG/0.8ML SC SOAJ", "drug_information": { "unit": "0.800000", "type": "UN" }, "code_information": [ { "code": "72511040001", "type": "NDC" } ], "standard_charges": [ { "minimum": 1277.29, "maximum": 4260.65, "gross_charge": 4532.61, "discounted_cash": 2492.94, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2628.91, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2474.81, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3626.09, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3839.12, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1318.99, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2175.65, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", 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charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3852.72, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3399.46, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1596.84, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3082.17, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4260.65, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3549.03, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2474.81, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3603.42, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3399.46, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3988.7, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2628.91, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2474.81, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ADEFOVIR DIPIVOXIL 10 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "42794000308", "type": "NDC" } ], "standard_charges": [ { "minimum": 13.97, "maximum": 46.6, "gross_charge": 49.57, "discounted_cash": 27.26, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.75, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.07, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.66, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.99, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.42, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.79, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.69, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.64, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.62, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.97, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.13, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.18, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.46, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.71, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.81, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.07, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.41, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.18, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.62, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.75, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.07, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ADENOSINE (DIAGNOSTIC) 3 MG/ML IV SOLN", "drug_information": { "unit": "30.000000", "type": "UN" }, "code_information": [ { "code": "55150019301", "type": "NDC" } ], "standard_charges": [ { "minimum": 127.75, "maximum": 426.12, "gross_charge": 453.32, "discounted_cash": 249.33, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 262.93, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 247.51, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 362.66, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 383.96, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 131.92, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 217.59, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 271.54, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 271.09, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 426.12, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 398.92, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 127.75, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 385.32, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 339.99, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 159.7, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 308.26, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 426.12, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 354.95, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 247.51, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 360.39, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 339.99, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 398.92, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 262.93, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 247.51, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ADENOSINE 6 MG/2ML IV SOLN", "drug_information": { "unit": "2.000000", "type": "UN" }, "code_information": [ { "code": "67457085502", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", 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"additional_payer_notes": "N/A", "standard_charge_dollar": 807.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 712.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 334.69, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 646.0, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 893.0, "standard_charge_percentage": 94.0, 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"standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 551.0, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 518.7, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AFLIBERCEPT 2 MG/0.05ML IZ SOLN", "drug_information": { "unit": "0.050000", "type": "UN" }, "code_information": [ { "code": "61755000502", "type": "NDC" } ], "standard_charges": [ { "minimum": 448.8, "maximum": 3476.67, "gross_charge": 3698.58, "discounted_cash": 2034.22, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2145.18, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 448.8, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2958.86, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3132.7, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1076.29, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1775.32, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2215.45, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2211.75, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3476.67, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3254.75, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1042.26, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3143.79, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2773.94, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1303.01, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", 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"additional_payer_notes": "N/A", "standard_charge_dollar": 2773.94, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3254.75, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2145.18, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 448.8, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "AFLIBERCEPT 2 MG/0.05ML IZ SOSY", "drug_information": { "unit": "0.050000", "type": "UN" }, "code_information": [ { "code": "61755000501", "type": "NDC" } ], "standard_charges": [ { "minimum": 448.8, "maximum": 5217.0, "gross_charge": 5550.0, "discounted_cash": 3052.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3219.0, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 448.8, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4440.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4700.85, "standard_charge_percentage": 85.0, "methodology": "percent of total 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"methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4884.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1563.99, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4717.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4162.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1955.27, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3774.0, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5217.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4345.65, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 605.88, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue 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schedule" } ], "additional_generic_notes": "" } ] }, { "description": "AFLIBERCEPT 8 MG/0.07ML IZ SOLN", "drug_information": { "unit": "0.070000", "type": "UN" }, "code_information": [ { "code": "61755005001", "type": "NDC" } ], "standard_charges": [ { "minimum": 182.2, "maximum": 5602.83, "gross_charge": 5960.46, "discounted_cash": 3278.25, "setting": "outpatient", "payers_information": [ { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4768.37, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1679.66, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4738.57, 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Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 182.2, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5245.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 245.97, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2861.02, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2099.87, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3457.07, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3457.07, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5602.83, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4667.04, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 3564.36, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5602.83, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "After cataract laser surgery", "code_information": [ { "code": "66821", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 404.37, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 1049.36, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 1904.09, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 1904.09, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 404.37, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 299.54, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "AGALSIDASE BETA 35 MG IV SOLR", "drug_information": { "unit": "7.000000", "type": "UN" }, "code_information": [ { "code": "58468004001", "type": "NDC" } ], "standard_charges": [ { "minimum": 6302.23, "maximum": 21022.34, "gross_charge": 22364.19, "discounted_cash": 12300.3, "setting": "outpatient", "payers_information": [ { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 18942.47, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19009.56, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16773.14, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10734.81, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 7878.9, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 12971.23, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6507.98, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16773.14, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19680.49, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 12971.23, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21022.34, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 17511.16, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 12210.85, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", 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"plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 15207.65, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 12210.85, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17891.35, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 6302.23, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 15189.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AGALSIDASE BETA 5 MG IV SOLR", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "58468004101", "type": "NDC" } ], "standard_charges": [ { "minimum": 900.17, "maximum": 3002.68, "gross_charge": 3194.34, "discounted_cash": 1756.89, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 1910.22, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3002.68, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1533.28, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1125.37, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1852.72, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2705.61, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2715.19, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2395.76, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1744.11, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2811.02, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1744.11, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1913.41, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2172.15, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1744.11, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 929.55, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2395.76, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2811.02, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2555.47, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 900.17, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2539.5, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1852.72, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3002.68, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2501.17, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Air injection into abdomen", "code_information": [ { "code": "49400", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 13993.79, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 25391.96, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 25391.96, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ALBENDAZOLE 200 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "43598045202", "type": "NDC" } ], "standard_charges": [ { "minimum": 3.62, "maximum": 12.07, "gross_charge": 12.84, "discounted_cash": 7.06, "setting": "outpatient", "payers_information": [ { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.27, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.62, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.21, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.91, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.63, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.45, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.07, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.05, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.74, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.63, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.3, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.69, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.73, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.01, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.16, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.52, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.45, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.68, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.07, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.01, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.3, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.01, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ALBUMIN HUMAN 25 % IV SOLN (MULTI-GPI)", "drug_information": { "unit": "50.000000", "type": "UN" }, "code_information": [ { "code": "68516521609", "type": "NDC" } ], "standard_charges": [ { "minimum": 60.31, "maximum": 201.16, "gross_charge": 214.0, "discounted_cash": 117.7, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 102.72, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.39, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 124.12, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 171.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.31, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 170.13, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 124.12, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 201.16, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 167.56, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 181.26, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 181.9, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 160.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 127.97, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 201.16, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 116.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 188.32, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 116.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 62.27, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 160.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 188.32, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 128.19, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 145.52, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 116.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ALBUMIN HUMAN 25 % IV SOLN (MULTI-GPI) HRS", "drug_information": { "unit": "50.000000", "type": "UN" }, "code_information": [ { "code": "68516521609_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 60.31, "maximum": 201.16, "gross_charge": 214.0, "discounted_cash": 117.7, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 127.97, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 201.16, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 62.27, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 160.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 188.32, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 116.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 188.32, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 116.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 128.19, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 145.52, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 116.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 102.72, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.39, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 124.12, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 171.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.31, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 170.13, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 181.26, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 181.9, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 160.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 124.12, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 201.16, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 167.56, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ALBUMIN HUMAN 25 % IV SOLN 50ML VIAL (BULK CHARGE)", "drug_information": { "unit": "50.000000", "type": "UN" }, "code_information": [ { "code": "68516521609_3", "type": "NDC" } ], "standard_charges": [ { "minimum": 60.31, "maximum": 201.16, "gross_charge": 214.0, "discounted_cash": 117.7, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 127.97, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 201.16, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 181.26, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 181.9, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 160.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 102.72, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.39, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 124.12, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 116.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 188.32, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 116.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 171.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.31, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 170.13, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 128.19, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 145.52, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 116.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 62.27, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 160.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 188.32, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 124.12, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 201.16, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 167.56, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ALBUMIN HUMAN 25 % IV SOLN FOR REPLACEMENT FLUIDS", "drug_information": { "unit": "50.000000", "type": "UN" }, "code_information": [ { "code": "68516521609_4", "type": "NDC" } ], "standard_charges": [ { "minimum": 60.31, "maximum": 201.16, "gross_charge": 214.0, "discounted_cash": 117.7, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 127.97, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 201.16, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 102.72, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.39, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 124.12, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 128.19, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 145.52, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 116.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 181.26, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 181.9, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 160.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 116.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 188.32, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 116.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 124.12, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 201.16, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 167.56, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 62.27, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 160.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 188.32, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 171.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.31, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 170.13, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ALBUMIN HUMAN 5 % IV SOLN", "drug_information": { "unit": "250.000000", "type": "UN" }, "code_information": [ { "code": "68516521804", "type": "NDC" } ], "standard_charges": [ { "minimum": 28.98, "maximum": 201.16, "gross_charge": 214.0, "discounted_cash": 117.7, "setting": "outpatient", "payers_information": [ { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 128.19, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 145.52, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.98, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 127.97, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 201.16, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 124.12, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 201.16, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 167.56, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 62.27, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 160.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 188.32, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 102.72, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.39, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 124.12, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 171.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.31, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 170.13, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 181.26, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 181.9, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 160.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.98, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 188.32, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.13, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "ALBUMIN HUMAN 5 % IV SOLN 250 ML BOTTLE (BULK CHARGE)", "drug_information": { "unit": "250.000000", "type": "UN" }, "code_information": [ { "code": "68516521401", "type": "NDC" } ], "standard_charges": [ { "minimum": 28.98, "maximum": 201.16, "gross_charge": 214.0, "discounted_cash": 117.7, "setting": "outpatient", "payers_information": [ { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 181.26, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 181.9, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 160.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 62.27, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 160.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 188.32, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 102.72, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.39, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 124.12, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 124.12, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 201.16, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 167.56, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 171.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.31, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 170.13, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.98, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 188.32, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.13, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 127.97, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 201.16, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 128.19, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 145.52, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.98, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "ALBUMIN HUMAN 5 % IV SOLN FOR REPLACEMENT FLUIDS", "drug_information": { "unit": "250.000000", "type": "UN" }, "code_information": [ { "code": "68516521401_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 28.98, "maximum": 201.16, "gross_charge": 214.0, "discounted_cash": 117.7, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 102.72, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.39, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 124.12, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 171.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.31, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 170.13, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 128.19, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 145.52, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.98, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 124.12, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 201.16, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 167.56, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 127.97, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 201.16, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 181.26, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 181.9, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 160.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.98, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 188.32, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.13, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 62.27, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 160.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 188.32, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ALBUMIN HUMAN 5 % SOLN (APHERESIS DOSE)", "drug_information": { "unit": "500.000000", "type": "UN" }, "code_information": [ { "code": "68516521402", "type": "NDC" } ], "standard_charges": [ { "minimum": 28.98, "maximum": 235.0, "gross_charge": 250.0, "discounted_cash": 137.5, "setting": "outpatient", "payers_information": [ { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 149.75, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 170.0, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.98, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 72.75, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 187.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 220.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 149.5, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 235.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 145.0, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 235.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 195.75, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.98, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 220.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.13, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 211.75, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 212.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 187.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 200.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 70.45, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 198.75, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 120.0, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.08, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 145.0, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ALBUMIN HUMAN 5 % SOLN (APHERESIS)", "drug_information": { "unit": "500.000000", "type": "UN" }, "code_information": [ { "code": "68516521402_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 28.98, "maximum": 235.0, "gross_charge": 250.0, "discounted_cash": 137.5, "setting": "outpatient", "payers_information": [ { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 211.75, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 212.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 187.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 72.75, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 187.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 220.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 149.75, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 170.0, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.98, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 149.5, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 235.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 120.0, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.08, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 145.0, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 145.0, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 235.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 195.75, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.98, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 220.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.13, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 200.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 70.45, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 198.75, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ALBUTEROL SULFATE (2.5 MG/3ML) 0.083% IN NEBU", "drug_information": { "unit": "3.000000", "type": "UN" }, "code_information": [ { "code": "60687039583", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ALBUTEROL SULFATE (5 MG/ML) 0.5% IN NEBU", "drug_information": { "unit": "3.000000", "type": "UN" }, "code_information": [ { "code": "69374033005", "type": "NDC" }, { "code": "00487990130", "type": "NDC" }, { "code": "73177014632", "type": "NDC" } ], "standard_charges": [ { "minimum": 7.05, "maximum": 23.5, "gross_charge": 25.0, "discounted_cash": 13.75, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.5, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.5, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.58, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.18, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.25, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.0, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.81, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.5, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.95, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.5, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.98, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.0, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.65, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.65, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.65, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.28, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.05, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.88, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" }, { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" }, { "minimum": 10.57, "maximum": 35.25, "gross_charge": 37.5, "discounted_cash": 20.63, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.0, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.21, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.75, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.75, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.25, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.36, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.57, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.81, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.91, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.13, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.76, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.13, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.46, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.5, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.48, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.48, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.48, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.43, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.25, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ALBUTEROL SULFATE (5MG/ML) IN NEBU 0.5 ML VIAL (BULK CHARGE)", "drug_information": { "unit": "3.000000", "type": "UN" }, "code_information": [ { "code": "69374033005_2", "type": "NDC" }, { "code": "00487990130_2", "type": "NDC" }, { "code": "73177014632_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 7.05, "maximum": 23.5, "gross_charge": 25.0, "discounted_cash": 13.75, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.0, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.81, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.5, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.98, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.0, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.65, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.05, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.88, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.5, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.5, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.58, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.65, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.65, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.18, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.25, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.95, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.5, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.28, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" }, { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "outpatient", "payers_information": [ { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" }, { "minimum": 10.57, "maximum": 35.25, "gross_charge": 37.5, "discounted_cash": 20.63, "setting": "outpatient", "payers_information": [ { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.76, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.13, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.91, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.13, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.75, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.25, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.36, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.46, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.5, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.48, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.43, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.25, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.48, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.48, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.0, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.21, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.75, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.57, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.81, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ALBUTEROL SULFATE 2 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68084094925", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.79, "maximum": 9.32, "gross_charge": 9.91, "discounted_cash": 5.45, "setting": "outpatient", "payers_information": [ { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.94, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.74, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.41, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.93, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.32, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.93, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.79, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.88, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.75, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.32, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.76, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.41, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.72, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.41, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.42, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.43, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.76, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.49, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.75, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.88, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.43, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.72, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ALBUTEROL SULFATE 2.5 MG/0.5ML IN NEBU", "drug_information": { "unit": "0.500000", "type": "UN" }, "code_information": [ { "code": "00487990130_3", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ALBUTEROL SULFATE 5 MG/ML CONTINUOUS NEBULIZATION (503B)", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "69374033005_3", "type": "NDC" } ], "standard_charges": [ { "minimum": 7.05, "maximum": 23.5, "gross_charge": 25.0, "discounted_cash": 13.75, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.65, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.65, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.05, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.88, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.5, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.5, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.58, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.28, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.98, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.0, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.65, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.95, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.5, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.0, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.81, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.5, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.18, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.25, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ALBUTEROL SULFATE 5 MG/ML CONTINUOUS NEBULIZATION MAINTENANCE", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "69374033005_4", "type": "NDC" } ], "standard_charges": [ { "minimum": 7.05, "maximum": 23.5, "gross_charge": 25.0, "discounted_cash": 13.75, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.95, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.5, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.98, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.0, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.65, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.05, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.88, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.5, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.5, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.58, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.0, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.81, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.5, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.28, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.65, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.65, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.18, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.25, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ALBUTEROL SULFATE HFA 108 (90 BASE) 8 GM INHALER (OR BULK CHARGE)", "drug_information": { "unit": "8.000000", "type": "GR" }, "code_information": [ { "code": "00173068224", "type": "NDC" } ], "standard_charges": [ { "minimum": 14.35, "maximum": 47.87, "gross_charge": 50.93, "discounted_cash": 28.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.74, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.35, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.49, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.51, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.63, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.81, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.54, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.87, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.88, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.45, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.94, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.54, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.81, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 44.82, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.81, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.14, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.29, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.2, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.46, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.87, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.82, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.2, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 44.82, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ALBUTEROL SULFATE HFA 108 (90 BASE) MCG/ACT IN AERS", "drug_information": { "unit": "8.000000", "type": "GR" }, "code_information": [ { "code": "00173068224_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 14.35, "maximum": 47.87, "gross_charge": 50.93, "discounted_cash": 28.01, "setting": "inpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.82, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.2, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 44.82, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.51, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.63, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.81, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.14, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.29, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.2, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.45, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.94, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.54, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.46, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.87, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.74, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.35, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.49, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.54, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.87, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.88, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.81, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 44.82, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.81, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ALDESLEUKIN 22000000 UNITS IV SOLR", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "73776002201", "type": "NDC" } ], "standard_charges": [ { "minimum": 2894.49, "maximum": 15655.15, "gross_charge": 16654.41, "discounted_cash": 9159.93, "setting": "outpatient", "payers_information": [ { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14106.29, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14156.25, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12490.81, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13323.53, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 4693.21, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 13240.26, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2894.49, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14655.88, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3907.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 9975.99, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 11325.0, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2894.49, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 9959.34, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 15655.15, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4846.43, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12490.81, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14655.88, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 9659.56, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15655.15, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 13040.4, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7994.12, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 5867.35, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 9659.56, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ALENDRONATE SODIUM 10 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "1671463101", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ALENDRONATE SODIUM 35 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "69097022316", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ALENDRONATE SODIUM 70 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "64980034214", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ALFUZOSIN HCL ER 10 MG PO TB24", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "57237011490", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "outpatient", "payers_information": [ { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ALGLUCOSIDASE ALFA 50 MG IV SOLR (LUMIZYME)", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "58468016001", "type": "NDC" } ], "standard_charges": [ { "minimum": 110.28, "maximum": 3626.26, "gross_charge": 3857.72, "discounted_cash": 2121.75, "setting": "outpatient", "payers_information": [ { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3086.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1087.11, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3066.89, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1851.71, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1359.07, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2237.48, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2306.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3626.26, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1122.6, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2893.29, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3394.79, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 110.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3394.79, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 148.87, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3267.49, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3279.06, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2893.29, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2237.48, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3626.26, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3020.59, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2310.77, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2623.25, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 110.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "ALIROCUMAB 75 MG/ML SC SOAJ", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "61755002002", "type": "NDC" } ], "standard_charges": [ { "minimum": 226.22, "maximum": 754.59, "gross_charge": 802.76, "discounted_cash": 441.52, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 465.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 754.59, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 628.56, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 679.94, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 682.35, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 602.07, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 642.21, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 226.22, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 638.19, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 233.6, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 602.07, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 706.43, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 385.32, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 282.81, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 465.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 480.85, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 545.88, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 438.31, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 438.31, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 706.43, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 438.31, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 480.05, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 754.59, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ALISKIREN FUMARATE 150 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "66993014130", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.83, "maximum": 9.43, "gross_charge": 10.03, "discounted_cash": 5.52, "setting": "outpatient", "payers_information": [ { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.53, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.01, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.82, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.48, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.48, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.83, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.48, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.81, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.53, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.82, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.02, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.83, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.97, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.92, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.83, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.82, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.43, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.85, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.43, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ALISKIREN FUMARATE 300 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "49884042511", "type": "NDC" } ], "standard_charges": [ { "minimum": 4.46, "maximum": 14.88, "gross_charge": 15.83, "discounted_cash": 8.71, "setting": "outpatient", "payers_information": [ { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.48, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.76, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.64, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.58, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.18, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.66, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.46, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.58, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.61, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.87, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.93, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.18, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.88, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.39, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.64, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.93, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.64, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.41, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.46, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.87, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.47, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.88, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Allgrft implnt knee w/scope", "code_information": [ { "code": "29867", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 9484.13, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 26376.2, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 47870.82, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 7025.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 47870.82, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 9484.13, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "ALLOPURINOL 0.2 MG/ML SUSPENSION", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "P0378013710", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "outpatient", "payers_information": [ { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ALLOPURINOL 100 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687067701", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "outpatient", "payers_information": [ { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ALLOPURINOL 20 MG/ML ORAL SUSPENSION", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "P0378013701", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ALLOPURINOL 300 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687068801", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ALLOPURINOL 50 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "0378013701", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "outpatient", "payers_information": [ { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ALLOPURINOL SODIUM 500 MG IV SOLR", "drug_information": { "unit": "500.000000", "type": "ME" }, "code_information": [ { "code": "67457018750", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.73, "maximum": 3167.06, "gross_charge": 3369.21, "discounted_cash": 1853.07, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1954.14, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3167.06, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2638.09, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2014.79, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3167.06, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2695.37, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 949.44, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2678.52, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 980.44, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2526.91, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2964.9, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2853.72, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2863.83, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2526.91, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.73, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2964.9, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.69, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2018.16, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2291.06, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.73, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1617.22, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1186.97, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1954.14, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ALPHA-LIPOIC ACID 600 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "47469004472", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ALPHA1-PROTEINASE INHIBITOR 1000 MG/20ML IV SOLN", "drug_information": { "unit": "1.000000", "type": "ME" }, "code_information": [ { "code": "13533070501_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.7, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.7, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.7, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "ALPHA1-PROTEINASE INHIBITOR 1000 MG/20ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED", "drug_information": { "unit": "1.000000", "type": "ME" }, "code_information": [ { "code": "13533070501", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.35, "maximum": 3.64, "gross_charge": 1.25, "discounted_cash": 0.69, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.7, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.1, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.44, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.73, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.35, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.99, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.06, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.06, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.94, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.36, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.94, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.1, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.85, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.7, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.18, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.73, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.18, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.98, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ALPHA1-PROTEINASE INHIBITOR 1000 MG/50ML IV SOLN", "drug_information": { "unit": "1.000000", "type": "ME" }, "code_information": [ { "code": "00944288401_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ALPHA1-PROTEINASE INHIBITOR 1000 MG/50ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED", "drug_information": { "unit": "1.000000", "type": "ME" }, "code_information": [ { "code": "00944288401", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.45, "maximum": 1.5, "gross_charge": 1.6, "discounted_cash": 0.88, "setting": "outpatient", "payers_information": [ { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.28, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.45, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.27, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.47, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.2, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.77, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.56, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.93, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.5, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.36, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.36, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.2, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.09, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.87, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.87, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.87, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.93, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.5, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.25, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ALPRAZOLAM 0.25 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687037701", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.25, "maximum": 7.52, "gross_charge": 8.0, "discounted_cash": 4.4, "setting": "inpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.33, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.78, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.8, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.4, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.25, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.36, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.26, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.79, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.44, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.84, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.82, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ALPRAZOLAM 0.5 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687038801", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.25, "maximum": 7.52, "gross_charge": 8.0, "discounted_cash": 4.4, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.33, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.26, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.84, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.82, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.79, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.44, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.78, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.8, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.4, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.25, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.36, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ALPRAZOLAM 1 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "R5976237211", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.25, "maximum": 7.52, "gross_charge": 8.0, "discounted_cash": 4.4, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.4, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.78, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.33, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.84, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.79, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.25, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.8, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.82, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.44, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.26, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.36, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ALPRAZOLAM 2 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00781108901", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.25, "maximum": 7.52, "gross_charge": 8.0, "discounted_cash": 4.4, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.4, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.78, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.33, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.84, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.79, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.25, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.8, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.82, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.44, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.26, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.36, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ALPRAZOLAM ER 0.5 MG PO TB24", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00228308306", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.25, "maximum": 7.52, "gross_charge": 8.0, "discounted_cash": 4.4, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.4, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.78, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.33, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.84, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.79, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.25, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.8, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.82, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.44, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.26, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.36, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ALPROSTADIL (VASODILATOR) 20 MCG IC SOLR", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00009370105", "type": "NDC" } ], "standard_charges": [ { "minimum": 80.41, "maximum": 1158.0, "gross_charge": 285.34, "discounted_cash": 156.94, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 165.5, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 155.8, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 247.68, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 83.03, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 136.96, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 170.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 170.63, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 268.22, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 251.1, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 80.41, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 242.54, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 214.01, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 100.53, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 194.03, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 268.22, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 223.42, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 155.8, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 226.85, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 214.01, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 251.1, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 165.5, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 155.8, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ALPROSTADIL 500 MCG/ML IJ SOLN", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00009316906", "type": "NDC" } ], "standard_charges": [ { "minimum": 115.76, "maximum": 1158.0, "gross_charge": 410.8, "discounted_cash": 225.94, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 238.26, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 224.3, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 356.57, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 119.54, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 197.18, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 246.07, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 245.66, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 386.15, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 361.5, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 115.76, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 349.18, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 308.1, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 144.72, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 279.34, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 386.15, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 321.66, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 224.3, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 326.59, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 308.1, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 361.5, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 238.26, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 224.3, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ALTEPLASE 100 MG IV SOLR", "drug_information": { "unit": "100.000000", "type": "UN" }, "code_information": [ { "code": "50242008527", "type": "NDC" } ], "standard_charges": [ { "minimum": 7216.63, "maximum": 24072.51, "gross_charge": 25609.05, "discounted_cash": 14084.98, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 14853.25, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 13982.54, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20487.24, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21690.87, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7452.23, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12292.34, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 15339.82, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 11394.0, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 24072.51, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 22535.96, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 7216.63, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21767.69, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19206.79, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 9022.07, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 17414.15, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 24072.51, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 20051.89, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 13982.54, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 15189.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19206.79, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 22535.96, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 14853.25, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 13982.54, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ALTEPLASE 100 MG IV SOLR (PE)", "drug_information": { "unit": "100.000000", "type": "UN" }, "code_information": [ { "code": "50242008527_3", "type": "NDC" } ], "standard_charges": [ { "minimum": 7236.36, "maximum": 24138.31, "gross_charge": 25679.05, "discounted_cash": 14123.48, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 14893.85, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 14020.76, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20543.24, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21750.16, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7472.6, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12325.94, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 15381.75, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 11394.0, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 24138.31, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 22597.56, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 7236.36, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21827.19, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19259.29, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 9046.73, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 17461.75, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 24138.31, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 20106.7, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 14020.76, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 15189.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19259.29, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 22597.56, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 14893.85, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 14020.76, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ALTEPLASE 100 MG IV SOLR (PE)|DISCARDED DRUG NOT ADMINISTERED", "drug_information": { "unit": "100.000000", "type": "UN" }, "code_information": [ { "code": "50242008527_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 7216.63, "maximum": 24072.51, "gross_charge": 25609.05, "discounted_cash": 14084.98, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 14853.25, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 13982.54, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20487.24, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21690.87, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7452.23, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12292.34, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 15339.82, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 11394.0, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 24072.51, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 22535.96, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 7216.63, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21767.69, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19206.79, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 9022.07, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 17414.15, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 24072.51, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 20051.89, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 13982.54, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 15189.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19206.79, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 22535.96, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 14853.25, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 13982.54, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ALTEPLASE 2 MG IJ SOLR", "drug_information": { "unit": "2.000000", "type": "UN" }, "code_information": [ { "code": "50242004164", "type": "NDC" } ], "standard_charges": [ { "minimum": 49.94, "maximum": 562.79, "gross_charge": 598.71, "discounted_cash": 329.29, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 347.25, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.94, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 478.97, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 507.11, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 174.22, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 287.38, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 358.63, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 358.03, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 562.79, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 526.86, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 168.72, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 508.9, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 449.03, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 210.93, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 407.12, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 562.79, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 468.79, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 67.42, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 475.97, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 449.03, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 526.86, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 347.25, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.94, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "ALTEPLASE 2 MG IJ SOLR (APHERESIS)", "drug_information": { "unit": "0.500000", "type": "UN" }, "code_information": [ { "code": "50242004164_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 49.94, "maximum": 562.79, "gross_charge": 598.71, "discounted_cash": 329.29, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 347.25, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.94, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 478.97, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 507.11, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 174.22, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 287.38, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 358.63, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 358.03, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 562.79, "standard_charge_percentage": 94.0, 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"additional_payer_notes": "N/A", "standard_charge_dollar": 210.93, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 407.12, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 562.79, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 468.79, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 67.42, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue 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schedule" } ], "additional_generic_notes": "" } ] }, { "description": "ALTEPLASE 2 MG IJ SOLR FOR 0.5 MG DOSE FOR IV LINE DECLOTTING", "drug_information": { "unit": "0.500000", "type": "UN" }, "code_information": [ { "code": "50242004164_3", "type": "NDC" } ], "standard_charges": [ { "minimum": 49.94, "maximum": 562.79, "gross_charge": 598.71, "discounted_cash": 329.29, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 347.25, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.94, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 478.97, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 507.11, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 174.22, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 287.38, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 358.63, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", 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"standard_charge_dollar": 347.25, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.94, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "ALTEPLASE 2 MG IJ SOLR FOR 1 MG DOSE FOR IV LINE DECLOTTING", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "50242004164_4", "type": "NDC" } ], "standard_charges": [ { "minimum": 49.94, "maximum": 562.79, "gross_charge": 598.71, "discounted_cash": 329.29, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 347.25, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.94, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 478.97, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 507.11, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 174.22, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 287.38, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 358.63, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 358.03, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 562.79, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 526.86, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 168.72, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 508.9, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 449.03, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 210.93, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 407.12, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 562.79, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 468.79, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 67.42, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 475.97, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 449.03, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 526.86, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 347.25, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.94, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "ALTEPLASE 2 MG IJ SOLR FOR 2 MG DOSE FOR IV LINE DECLOTTING", "drug_information": { "unit": "2.000000", "type": "UN" }, "code_information": [ { "code": "50242004164_5", "type": "NDC" } ], "standard_charges": [ { "minimum": 49.94, "maximum": 562.79, "gross_charge": 598.71, "discounted_cash": 329.29, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 347.25, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.94, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 478.97, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 507.11, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 174.22, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 287.38, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 358.63, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 358.03, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 562.79, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 526.86, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 168.72, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 508.9, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 449.03, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 210.93, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 407.12, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 562.79, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 468.79, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 67.42, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 475.97, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 449.03, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 526.86, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 347.25, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.94, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "ALTEPLASE 50 MG IV SOLR", "drug_information": { "unit": "50.000000", "type": "UN" }, "code_information": [ { "code": "50242004413", "type": "NDC" } ], "standard_charges": [ { "minimum": 3608.32, "maximum": 12036.27, "gross_charge": 12804.54, "discounted_cash": 7042.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 7426.63, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 6991.28, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10243.63, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10845.45, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3726.12, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6146.18, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7669.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 7657.11, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12036.27, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11268.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3608.32, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10883.86, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9603.41, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 4511.04, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 8707.09, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 12036.27, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 10025.95, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6991.28, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 10179.61, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9603.41, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11268.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7426.63, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6991.28, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ALUM & MAG HYDROXIDE-SIMETH 400-400-40 MG/5ML PO SUSP", "drug_information": { "unit": "30.000000", "type": "UN" }, "code_information": [ { "code": "00121176230", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.08, "maximum": 6.93, "gross_charge": 7.37, "discounted_cash": 4.05, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.27, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.02, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.9, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.24, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.14, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.54, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.41, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.41, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.93, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.49, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.08, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.26, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.53, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.6, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.01, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.93, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.77, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.02, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.86, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.53, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.49, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.27, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.02, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ALUM HYDROXIDE-MAG CARBONATE 95-358 MG/15ML PO SUSP", "drug_information": { "unit": "355.000000", "type": "UN" }, "code_information": [ { "code": "00904772714", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.12, "maximum": 7.08, "gross_charge": 7.53, "discounted_cash": 4.14, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.11, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.02, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.38, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.19, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.61, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.51, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.5, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.08, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.63, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.12, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.65, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.65, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.12, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.08, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.9, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.11, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.99, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.65, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.63, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.11, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ALUM POTASSIUM SULFATE 10% IRRIGATION SOLN", "drug_information": { "unit": "300.000000", "type": "UN" }, "code_information": [ { "code": "05446063730", "type": "NDC" } ], "standard_charges": [ { "minimum": 70.45, "maximum": 1158.0, "gross_charge": 250.0, "discounted_cash": 137.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 145.0, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 136.5, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 217.0, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 72.75, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 120.0, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 149.75, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 149.5, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 235.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 220.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 70.45, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 212.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 187.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.08, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 170.0, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 235.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 195.75, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 136.5, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 198.75, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 187.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 220.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 145.0, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 136.5, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ALUMINUM CHLORIDE 20 % EX SOLN", "drug_information": { "unit": "35.000000", "type": "UN" }, "code_information": [ { "code": "00096070735", "type": "NDC" } ], "standard_charges": [ { "minimum": 5.42, "maximum": 18.1, "gross_charge": 19.25, "discounted_cash": 10.59, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.17, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.51, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.4, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.3, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.6, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.24, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.53, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.51, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.1, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.94, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.42, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.36, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.44, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.78, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.09, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.1, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.07, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.51, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.3, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.44, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.94, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.17, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.51, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ALUMINUM HYDROXIDE GEL 320 MG/5ML PO SUSP", "drug_information": { "unit": "473.000000", "type": "UN" }, "code_information": [ { "code": "00536009185", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.84, "maximum": 9.48, "gross_charge": 10.08, "discounted_cash": 5.54, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.85, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.5, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.06, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.54, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.93, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.84, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.04, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.03, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.48, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.87, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.84, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.57, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.56, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.55, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.85, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.48, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.89, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.5, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.01, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.56, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.87, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.85, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.5, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AMANTADINE HCL 100 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687042201", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AMANTADINE HCL 50 MG/5ML PO SOLN", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "00121064610", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.97, "maximum": 6.58, "gross_charge": 7.0, "discounted_cash": 3.85, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.06, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.82, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.6, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.93, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.04, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.36, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.19, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.19, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.58, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.16, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.97, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.95, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.25, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.47, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.76, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.58, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.48, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.82, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.57, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.25, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.16, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.06, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.82, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AMBRISENTAN 10 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00591240630", "type": "NDC" } ], "standard_charges": [ { "minimum": 70.62, "maximum": 235.55, "gross_charge": 250.59, "discounted_cash": 137.82, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 145.34, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 136.82, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 200.47, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 212.25, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 72.92, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 120.28, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 150.1, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 149.85, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 235.55, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 220.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 70.62, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 213.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 187.94, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.28, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 170.4, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 235.55, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 196.21, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 136.82, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 199.22, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 187.94, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 220.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 145.34, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 136.82, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AMBRISENTAN 5 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00378427093", "type": "NDC" } ], "standard_charges": [ { "minimum": 10.82, "maximum": 36.09, "gross_charge": 38.39, "discounted_cash": 21.11, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.27, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.96, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.71, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.52, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.17, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.43, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.0, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.09, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.78, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.82, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.63, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.79, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.52, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.11, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.09, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.06, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.96, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.52, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.79, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.78, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.27, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.96, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AMIKACIN INTRAVITREAL INJ (0.2MG/0.1ML)", "drug_information": { "unit": "0.100000", "type": "UN" }, "code_information": [ { "code": "08252003300", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AMIKACIN INTRAVITREAL INJ (0.4MG/0.1ML)", "drug_information": { "unit": "0.100000", "type": "UN" }, "code_information": [ { "code": "08252003400", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AMIKACIN INTRAVITREAL INJ (0.6MG/0.1ML)", "drug_information": { "unit": "0.100000", "type": "UN" }, "code_information": [ { "code": "08252000300", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AMIKACIN OPHTHALMIC SOLN 25 MG/ML", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "08252001900", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AMIKACIN SULFATE 1 G/4 ML IJ SOLN FOR INHALATION", "drug_information": { "unit": "4.000000", "type": "UN" }, "code_information": [ { "code": "23155029042_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AMIKACIN SULFATE 1 GM/4ML IJ SOLN", "drug_information": { "unit": "4.000000", "type": "UN" }, "code_information": [ { "code": "23155029042", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AMIKACIN SULFATE 500 MG/2ML IJ SOLN", "drug_information": { "unit": "2.000000", "type": "UN" }, "code_information": [ { "code": "00641616710", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AMILORIDE HCL 5 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "R0574029201", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AMINO ACID 5 % IV SOLN", "drug_information": { "unit": "1000.000000", "type": "UN" }, "code_information": [ { "code": "71266802001", "type": "NDC" } ], "standard_charges": [ { "minimum": 227.55, "maximum": 759.05, "gross_charge": 807.5, "discounted_cash": 444.13, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 468.35, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 440.9, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 646.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 683.95, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 234.98, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 387.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 483.69, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 482.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 759.05, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 710.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 227.55, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 686.38, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 605.63, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 284.48, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 549.1, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 759.05, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 632.27, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 440.9, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 641.96, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 605.63, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 710.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 468.35, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 440.9, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AMINO ACID INFUSION IN D10W 3 % IV SOLN (503B)", "drug_information": { "unit": "250.000000", "type": "UN" }, "code_information": [ { "code": "72196040401", "type": "NDC" } ], "standard_charges": [ { "minimum": 12.55, "maximum": 1158.0, "gross_charge": 44.55, "discounted_cash": 24.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.84, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.32, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.67, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.96, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.38, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.69, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.64, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.88, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.55, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.87, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.41, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.69, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.29, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.88, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.88, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.32, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.42, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.41, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.84, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.32, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AMINO ACID INFUSION IN D10W 3 % W/ CALCIUM GLUC 2.33 MEQ HEPARIN 125 UNITS IV SOLN (503B)", "drug_information": { "unit": "250.000000", "type": "UN" }, "code_information": [ { "code": "72196042801", "type": "NDC" } ], "standard_charges": [ { "minimum": 14.01, "maximum": 1158.0, "gross_charge": 49.7, "discounted_cash": 27.34, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.83, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.14, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.14, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.46, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.86, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.77, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.72, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.72, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.74, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.01, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.25, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.28, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.51, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.72, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.92, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.14, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.51, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.28, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.74, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.83, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.14, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AMINO ACID INFUSION IN D10W 4.25 % IV SOLN", "drug_information": { "unit": "1000.000000", "type": "UN" }, "code_information": [ { "code": "00338113403", "type": "NDC" } ], "standard_charges": [ { "minimum": 8.65, "maximum": 1158.0, "gross_charge": 30.69, "discounted_cash": 16.88, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.76, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.64, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.93, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.73, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.38, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.35, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.85, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.01, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.65, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.09, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.02, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.81, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.87, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.85, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.03, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.76, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.4, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.02, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.01, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.76, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { 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"methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1514.36, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1417.7, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 453.99, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1369.37, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": 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{ "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 879.62, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1280.76, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1208.27, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1417.7, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 934.39, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 879.62, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AMINOCAPROIC ACID 250 MG/ML IV SOLN", "drug_information": { "unit": "20.000000", "type": "UN" }, "code_information": [ { "code": "00517912025", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 1158.0, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.72, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", 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"plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AMINOCAPROIC ACID 500 MG PO TABS", "drug_information": { "unit": "2.000000", "type": "UN" }, "code_information": [ { "code": "60687073925", "type": "NDC" } ], "standard_charges": [ { "minimum": 20.18, "maximum": 67.32, "gross_charge": 71.62, "discounted_cash": 39.39, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.54, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.1, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 57.3, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.66, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.84, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.38, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.9, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.83, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 67.32, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.03, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.18, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 53.72, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.23, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 48.7, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 67.32, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 56.08, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.1, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 56.94, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 53.72, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.03, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.54, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.1, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AMINOLEVULINIC ACID HCL 1.5 G PO SOLR", "drug_information": { "unit": "50.000000", "type": "UN" }, "code_information": [ { "code": "59137023101", "type": "NDC" } ], "standard_charges": [ { "minimum": 3602.53, "maximum": 12016.96, "gross_charge": 12784.0, "discounted_cash": 7031.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 7414.72, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 6980.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10227.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10828.05, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3720.14, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6136.32, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7657.62, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 7644.83, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12016.96, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11249.92, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3602.53, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10866.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9588.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 4503.8, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 8693.12, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 12016.96, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 10009.87, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6980.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 10163.28, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9588.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11249.92, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7414.72, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6980.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AMINOLEVULINIC ACID HCL 20 % EX SOLR", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "67308010106", "type": "NDC" } ], "standard_charges": [ { "minimum": 216.75, "maximum": 1317.73, "gross_charge": 1401.84, "discounted_cash": 771.01, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 813.07, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 216.75, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1121.47, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1187.36, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 407.94, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 672.88, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 839.7, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 838.3, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1317.73, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1233.62, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 395.04, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1191.56, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1051.38, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 493.87, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 953.25, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1317.73, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1097.64, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 292.61, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1114.46, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1051.38, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1233.62, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 813.07, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 216.75, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "AMINOPHYLLINE 2 MG/ML SOLUTION", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "P0409592101", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AMINOPHYLLINE 25 MG/ML IV SOLN", "drug_information": { "unit": "20.000000", "type": "UN" }, "code_information": [ { "code": "00409592201", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AMIODARONE 10MG/ML SUSPENSION", "drug_information": { "unit": "20.000000", "type": "UN" }, "code_information": [ { "code": "08252000155", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AMIODARONE HCL 100 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00245014401", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AMIODARONE HCL 150 MG/100 ML DRIP RTU", "drug_information": { "unit": "100.000000", "type": "UN" }, "code_information": [ { "code": "43066015010", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AMIODARONE HCL 150 MG/3 ML IV SOLN 3 ML VIAL (BULK CHARGE)", "drug_information": { "unit": "3.000000", "type": "UN" }, "code_information": [ { "code": "00143987525", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AMIODARONE HCL 150 MG/3ML IV SOLN", "drug_information": { "unit": "3.000000", "type": "UN" }, "code_information": [ { "code": "00143987525_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AMIODARONE HCL 150 MG/3ML IV SOLN -CODE USE PEDS", "drug_information": { "unit": "3.000000", "type": "UN" }, "code_information": [ { "code": "00143987525_3", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AMIODARONE HCL 200 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687043701", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AMIODARONE HCL 360 MG/200 ML DRIP RTU", "drug_information": { "unit": "200.000000", "type": "UN" }, "code_information": [ { "code": "43066036020", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AMIODARONE HCL 450 MG/9ML IV SOLN", "drug_information": { "unit": "9.000000", "type": "UN" }, "code_information": [ { "code": "63323061609", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AMIODARONE HCL 900 MG/18ML IV SOLN", "drug_information": { "unit": "18.000000", "type": "UN" }, "code_information": [ { "code": "67457015318", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AMITRIPTYLINE HCL 10 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "50268003715", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AMITRIPTYLINE HCL 100 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "R1672917501", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AMITRIPTYLINE HCL 25 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687043301", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AMITRIPTYLINE HCL 50 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687044401", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AMITRIPTYLINE HCL 75 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "1657110801", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AMIVANTAMAB-VMJW 350 MG/7ML IV SOLN", "drug_information": { "unit": "7.000000", "type": "UN" }, "code_information": [ { "code": "57894050101", "type": "NDC" } ], "standard_charges": [ { "minimum": 3082.62, "maximum": 10282.71, "gross_charge": 10939.05, "discounted_cash": 6016.48, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 6344.65, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5972.72, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8751.24, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9265.38, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3183.26, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5250.74, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6552.49, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 6541.55, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10282.71, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9626.36, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3082.62, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9298.19, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8204.29, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3853.83, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7438.55, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 10282.71, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8565.28, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5972.72, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 8696.54, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8204.29, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9626.36, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6344.65, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5972.72, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AMLODIPINE BENZOATE 1 MG/ML PO SUSP", "drug_information": { "unit": "150.000000", "type": "UN" }, "code_information": [ { "code": "52652500101", "type": "NDC" } ], "standard_charges": [ { "minimum": 374.48, "maximum": 1249.17, "gross_charge": 1328.9, "discounted_cash": 730.9, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 770.76, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 725.58, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1063.12, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1125.58, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 386.71, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 637.87, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 796.01, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 794.68, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1249.17, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1169.43, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 374.48, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1129.57, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 996.68, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 468.17, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 903.65, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1249.17, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1040.53, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 725.58, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1056.48, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 996.68, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1169.43, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 770.76, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 725.58, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AMLODIPINE BESY-BENAZEPRIL HCL 10-40 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00078037905", "type": "NDC" } ], "standard_charges": [ { "minimum": 10.38, "maximum": 34.64, "gross_charge": 36.85, "discounted_cash": 20.27, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.37, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.12, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.48, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.21, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.72, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.69, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.07, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.04, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.64, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.43, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.38, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.64, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.98, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.06, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.64, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.85, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.12, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.3, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.64, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.43, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.37, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.12, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AMLODIPINE BESY-BENAZEPRIL HCL 5-10 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00078040505", "type": "NDC" } ], "standard_charges": [ { "minimum": 7.68, "maximum": 25.62, "gross_charge": 27.26, "discounted_cash": 14.99, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.81, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.88, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.81, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.09, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.93, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.08, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.33, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.3, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.62, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.99, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.68, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.45, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.6, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.54, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.62, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.34, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.88, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.67, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.45, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.99, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.81, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.88, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AMLODIPINE BESYLATE 10 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687049601", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AMLODIPINE BESYLATE 2.5 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00904636961", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AMLODIPINE BESYLATE 5 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687048801", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AMMONIA AROMATIC IN INHA", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "08252062022", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AMMONIUM LACTATE 12 % EX LOTN", "drug_information": { "unit": "226.000000", "type": "GR" }, "code_information": [ { "code": "00904598426", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.47, "maximum": 8.25, "gross_charge": 8.78, "discounted_cash": 4.83, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.09, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.79, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.02, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.44, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.55, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.21, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.26, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.25, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.25, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.73, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.47, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.46, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.59, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.97, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.25, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.87, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.79, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.98, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.59, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.73, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.09, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.79, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AMOXICILLIN 125 MG/5ML PO SUSR", "drug_information": { "unit": "80.000000", "type": "UN" }, "code_information": [ { "code": "00781603958", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.54, "maximum": 5.15, "gross_charge": 5.48, "discounted_cash": 3.01, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.99, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.38, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.59, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.63, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.28, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.28, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.15, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.82, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.54, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.66, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.11, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.93, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.73, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.15, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.29, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.99, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.36, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.11, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.82, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.99, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AMOXICILLIN 250 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "R0781202001", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AMOXICILLIN 250 MG PO CHEW", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00093226801", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AMOXICILLIN 250 MG/5ML PO SUSR", "drug_information": { "unit": "100.000000", "type": "UN" }, "code_information": [ { "code": "00143988901", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.49, "maximum": 4.98, "gross_charge": 5.3, "discounted_cash": 2.92, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.07, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.89, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.24, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.49, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.54, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.54, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.17, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.17, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.98, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.66, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.49, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.51, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.98, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.87, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.6, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.98, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.15, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.89, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.21, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.98, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.66, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.07, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.89, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AMOXICILLIN 400 MG/5ML PO SUSR", "drug_information": { "unit": "50.000000", "type": "UN" }, "code_information": [ { "code": "65862007150", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.76, "maximum": 5.86, "gross_charge": 6.23, "discounted_cash": 3.43, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.61, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.98, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.28, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.81, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.99, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.73, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.73, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.86, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.48, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.76, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.3, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.67, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.19, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.24, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.86, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.88, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.95, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.67, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.48, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.61, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AMOXICILLIN 500 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "R0781261305", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AMOXICILLIN 875 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00093226401", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AMOXICILLIN-POT CLAVULANATE 250-125 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687078194", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.12, "maximum": 7.07, "gross_charge": 7.52, "discounted_cash": 4.14, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.36, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.11, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.02, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.37, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.19, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.61, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.5, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.5, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.07, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.62, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.12, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.64, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.65, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.11, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.07, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.89, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.11, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.98, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.64, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.62, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.36, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.11, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AMOXICILLIN-POT CLAVULANATE 250-62.5 MG/5ML PO SUSR", "drug_information": { "unit": "100.000000", "type": "UN" }, "code_information": [ { "code": "60432006500", "type": "NDC" } ], "standard_charges": [ { "minimum": 5.68, "maximum": 18.94, "gross_charge": 20.15, "discounted_cash": 11.08, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.69, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.0, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.12, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.07, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.86, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.67, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.07, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.05, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.94, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.73, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.68, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.13, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.11, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.1, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.7, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.94, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.78, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.0, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.02, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.11, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.73, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.69, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.0, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AMOXICILLIN-POT CLAVULANATE 400-57 MG/5ML PO SUSR", "drug_information": { "unit": "50.000000", "type": "UN" }, "code_information": [ { "code": "65862053450", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.36, "maximum": 7.88, "gross_charge": 8.38, "discounted_cash": 4.61, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.86, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.58, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.7, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.1, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.44, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.02, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.02, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.01, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.88, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.37, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.36, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.12, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.29, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.95, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.7, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.88, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.56, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.58, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.66, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.29, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.37, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.86, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.58, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AMOXICILLIN-POT CLAVULANATE 500-125 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687079201", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.39, "maximum": 4.64, "gross_charge": 4.94, "discounted_cash": 2.72, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.87, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.7, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.95, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.18, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.44, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.37, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.95, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.35, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.39, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.2, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.71, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.74, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.36, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.87, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.7, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.93, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.71, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.35, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.87, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.7, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AMOXICILLIN-POT CLAVULANATE 600-42.9 MG/5ML PO SUSR", "drug_information": { "unit": "75.000000", "type": "UN" }, "code_information": [ { "code": "00781613957", "type": "NDC" } ], "standard_charges": [ { "minimum": 4.24, "maximum": 14.13, "gross_charge": 15.03, "discounted_cash": 8.27, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.72, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.21, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.02, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.73, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.21, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.0, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.99, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.13, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.23, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.24, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.78, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.3, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.22, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.13, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.77, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.21, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.95, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.23, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.72, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.21, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AMOXICILLIN-POT CLAVULANATE 875-125 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687080301", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.43, "maximum": 4.78, "gross_charge": 5.09, "discounted_cash": 2.8, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.95, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.78, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.07, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.31, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.48, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.44, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.05, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.04, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.78, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.48, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.43, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.33, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.82, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.79, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.46, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.78, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.99, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.78, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.05, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.82, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.48, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.95, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.78, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AMOXICILLIN-POT CLAVULANATE ER 1000-62.5 MG PO TB12", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00781194382", "type": "NDC" } ], "standard_charges": [ { "minimum": 3.04, "maximum": 10.14, "gross_charge": 10.79, "discounted_cash": 5.93, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.26, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.89, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.63, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.14, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.14, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.18, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.46, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.45, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.14, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.5, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.04, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.09, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.8, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.34, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.14, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.45, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.89, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.58, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.09, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.5, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.26, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.89, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AMPHETAMINE-DEXTROAMPHET ER 10 MG PO CP24", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "3172218601", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.25, "maximum": 7.52, "gross_charge": 8.0, "discounted_cash": 4.4, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.4, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.78, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.33, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.84, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.79, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", 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"payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.82, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.44, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.26, 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"standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AMPHETAMINE-DEXTROAMPHET ER 15 MG PO CP24", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "3172218701", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.25, "maximum": 7.52, "gross_charge": 8.0, "discounted_cash": 4.4, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", 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"percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.8, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.82, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.44, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.26, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.36, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AMPHETAMINE-DEXTROAMPHET ER 20 MG PO CP24", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "54092038701", "type": "NDC" } ], "standard_charges": [ { "minimum": 4.55, "maximum": 15.16, "gross_charge": 16.13, "discounted_cash": 8.87, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.36, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.81, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.9, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.66, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.69, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.74, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.66, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.65, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.16, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.19, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.55, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.71, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.1, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.68, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.97, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.16, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.63, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.81, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.82, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.1, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.19, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.36, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.81, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AMPHETAMINE-DEXTROAMPHET ER 25 MG PO CP24", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "54092038901", "type": "NDC" } ], "standard_charges": [ { "minimum": 4.55, "maximum": 15.16, "gross_charge": 16.13, "discounted_cash": 8.87, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.36, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.81, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.9, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.66, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.69, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.74, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.66, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.65, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.16, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.19, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.55, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.71, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.1, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.68, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.97, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.16, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.63, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.81, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.82, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.1, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.19, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.36, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.81, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AMPHETAMINE-DEXTROAMPHET ER 5 MG PO CP24", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "3172218501", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.25, "maximum": 7.52, "gross_charge": 8.0, "discounted_cash": 4.4, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.4, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.78, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.33, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.84, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.79, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.25, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.8, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.82, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.44, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.26, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.36, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AMPHETAMINE-DEXTROAMPHETAMINE 10 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "1153419201", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.25, "maximum": 7.52, "gross_charge": 8.0, "discounted_cash": 4.4, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { 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"methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.79, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.25, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.8, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.82, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.44, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": 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total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AMPHETAMINE-DEXTROAMPHETAMINE 20 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00527150537", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.25, "maximum": 7.52, "gross_charge": 8.0, "discounted_cash": 4.4, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.4, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.78, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", 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"additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.25, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.8, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.82, "standard_charge_percentage": 35.0, 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6.36, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AMPHETAMINE-DEXTROAMPHETAMINE 30 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00555097402", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.25, "maximum": 7.52, "gross_charge": 8.0, "discounted_cash": 4.4, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.4, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.78, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.33, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.84, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.79, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.25, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.8, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.82, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.44, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.26, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.36, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AMPHETAMINE-DEXTROAMPHETAMINE 5 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "R0555097102", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.25, "maximum": 7.52, "gross_charge": 8.0, "discounted_cash": 4.4, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.4, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.78, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.33, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.84, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.79, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.25, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.8, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.82, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.44, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.26, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.36, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AMPHOTERICIN B 0.167 MG/ML SUSPENSION", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "P3982210555", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AMPHOTERICIN B 5 MG/ML SUSPENSION", "drug_information": { "unit": "2.000000", "type": "UN" }, "code_information": [ { "code": "P3982210557", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.68, "maximum": 8.93, "gross_charge": 9.5, "discounted_cash": 5.23, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.51, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.19, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.6, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.05, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.76, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.56, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.69, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.68, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.93, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.36, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.68, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.08, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.13, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.35, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.46, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.93, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.44, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.19, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.55, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.13, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.36, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.51, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.19, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AMPHOTERICIN B 50 MG IV SOLR", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "39822105505", "type": "NDC" } ], "standard_charges": [ { "minimum": 24.22, "maximum": 80.79, "gross_charge": 85.95, "discounted_cash": 47.27, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.85, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.93, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 68.76, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 72.8, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.26, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 51.48, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 51.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 80.79, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.64, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.22, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 73.06, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 64.46, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.28, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 58.45, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 80.79, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 67.3, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.93, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 68.33, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 64.46, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.64, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.85, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.93, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AMPHOTERICIN B 50 MG IV SOLR (INTRA-ARTICULAR ONLY)", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "39822105505_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 24.22, "maximum": 80.79, "gross_charge": 85.95, "discounted_cash": 47.27, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.85, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.93, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 68.76, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 72.8, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.26, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 51.48, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 51.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 80.79, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.64, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.22, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 73.06, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 64.46, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.28, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 58.45, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 80.79, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 67.3, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.93, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 68.33, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 64.46, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.64, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.85, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.93, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AMPHOTERICIN B LIPID 5 MG/ML IV SUSP", "drug_information": { "unit": "20.000000", "type": "UN" }, "code_information": [ { "code": "57665010141", "type": "NDC" } ], "standard_charges": [ { "minimum": 6.08, "maximum": 268.18, "gross_charge": 285.3, "discounted_cash": 156.92, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 165.47, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.08, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 228.24, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 241.65, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 83.02, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 136.94, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 170.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 170.61, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 268.18, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 251.06, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 80.4, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 242.51, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 213.98, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 100.51, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 194.0, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 268.18, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 223.39, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.2, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 226.81, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 213.98, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 251.06, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 165.47, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.08, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "AMPHOTERICIN B LIPID CPLX (ABELCET) INH SYR", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "57665010141_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 6.08, "maximum": 268.18, "gross_charge": 285.3, "discounted_cash": 156.92, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 165.47, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.08, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 228.24, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 241.65, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 83.02, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 136.94, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 170.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 170.61, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 268.18, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 251.06, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 80.4, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 242.51, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 213.98, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 100.51, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 194.0, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 268.18, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 223.39, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.2, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 226.81, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 213.98, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 251.06, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 165.47, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.08, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "AMPHOTERICIN B LIPOSOME (AMBISOME) INH SYR", "drug_information": { "unit": "3.000000", "type": "UN" }, "code_information": [ { "code": "00469305130", "type": "NDC" } ], "standard_charges": [ { "minimum": 12.74, "maximum": 263.95, "gross_charge": 280.8, "discounted_cash": 154.44, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 162.86, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.74, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 224.64, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 237.84, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 81.71, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 134.78, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 168.2, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 167.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 263.95, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 247.1, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 79.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 238.68, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 210.6, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 98.93, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 190.94, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 263.95, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 219.87, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.2, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 223.24, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 210.6, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 247.1, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 162.86, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.74, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "AMPHOTERICIN B LIPOSOME (AMBISOME) INH SYR|DISCARDED DRUG NOT ADMINISTERED", "drug_information": { "unit": "3.000000", "type": "UN" }, "code_information": [ { "code": "00469305130_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 12.74, "maximum": 263.95, "gross_charge": 280.8, "discounted_cash": 154.44, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 162.86, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.74, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 224.64, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 237.84, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 81.71, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 134.78, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 168.2, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 167.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 263.95, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 247.1, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 79.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 238.68, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 210.6, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 98.93, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 190.94, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 263.95, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 219.87, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.2, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 223.24, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 210.6, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 247.1, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 162.86, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.74, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "AMPHOTERICIN B LIPOSOME 2 MG/ML LOCK SYRINGE", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00469305130_4", "type": "NDC" } ], "standard_charges": [ { "minimum": 12.74, "maximum": 329.75, "gross_charge": 350.8, "discounted_cash": 192.94, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 203.46, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.74, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 280.64, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 297.13, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 102.08, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 168.38, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 210.13, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 209.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 329.75, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 308.7, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 98.86, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 298.18, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 263.1, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 123.59, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 238.54, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 329.75, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 274.68, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.2, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 278.89, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 263.1, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 308.7, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 203.46, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.74, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "AMPHOTERICIN B LIPOSOME 50 MG IV SUSR", "drug_information": { "unit": "13.000000", "type": "UN" }, "code_information": [ { "code": "00469305130_5", "type": "NDC" } ], "standard_charges": [ { "minimum": 12.74, "maximum": 615.89, "gross_charge": 655.2, "discounted_cash": 360.36, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 380.02, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.74, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 524.16, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 554.95, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 190.66, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 314.5, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 392.46, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 391.81, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 615.89, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 576.58, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 184.64, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 556.92, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 491.4, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 230.83, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 445.54, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 615.89, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 513.02, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.2, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 520.88, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 491.4, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 576.58, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 380.02, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.74, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "AMPHOTERICIN B LIPOSOME 50 MG IV SUSR|DISCARDED DRUG NOT ADMINISTERED", "drug_information": { "unit": "13.000000", "type": "UN" }, "code_information": [ { "code": "00469305130_3", "type": "NDC" } ], "standard_charges": [ { "minimum": 12.74, "maximum": 263.95, "gross_charge": 280.8, "discounted_cash": 154.44, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 162.86, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.74, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 224.64, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 237.84, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 81.71, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 134.78, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 168.2, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 167.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 263.95, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 247.1, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 79.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 238.68, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 210.6, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 98.93, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 190.94, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 263.95, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 219.87, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.2, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 223.24, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 210.6, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 247.1, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 162.86, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.74, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "AMPHOTERICIN B OPHTHALMIC SOLN 1.5 MG/ML", "drug_information": { "unit": "0.050000", "type": "UN" }, "code_information": [ { "code": "9993000510_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AMPHOTERICIN B OPHTHALMIC SOLN 5 MG/ML", "drug_information": { "unit": "0.050000", "type": "UN" }, "code_information": [ { "code": "9993000510", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AMPHOTERICIN INTRAVITREAL INJ (10MCG/0.1ML)", "drug_information": { "unit": "0.100000", "type": "UN" }, "code_information": [ { "code": "08252000158", "type": "NDC" } ], "standard_charges": [ { "minimum": 56.06, "maximum": 186.98, "gross_charge": 198.92, "discounted_cash": 109.41, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 115.37, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 108.61, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 159.14, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 168.49, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 57.89, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 95.48, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 119.15, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 118.95, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 186.98, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 175.05, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 56.06, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 169.08, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 149.19, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 70.08, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 135.27, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 186.98, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 155.75, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 108.61, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 158.14, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 149.19, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 175.05, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 115.37, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 108.61, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AMPHOTERICIN INTRAVITREAL INJ (5MCG/0.05ML)", "drug_information": { "unit": "0.050000", "type": "UN" }, "code_information": [ { "code": "9986000501", "type": "NDC" } ], "standard_charges": [ { "minimum": 55.99, "maximum": 186.76, "gross_charge": 198.68, "discounted_cash": 109.27, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 115.23, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 108.48, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 158.94, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 168.28, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 57.82, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 95.37, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 119.01, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 118.81, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 186.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 174.84, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.99, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 168.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 149.01, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 69.99, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 135.1, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 186.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 155.57, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 108.48, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 157.95, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 149.01, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 174.84, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 115.23, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 108.48, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AMPHOTERICIN INTRAVITREAL INJ (5MCG/0.1ML)", "drug_information": { "unit": "0.100000", "type": "UN" }, "code_information": [ { "code": "9986000501_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 55.99, "maximum": 186.76, "gross_charge": 198.68, "discounted_cash": 109.27, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 115.23, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 108.48, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 158.94, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 168.28, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 57.82, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 95.37, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 119.01, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 118.81, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 186.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 174.84, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.99, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 168.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 149.01, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 69.99, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 135.1, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 186.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 155.57, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 108.48, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 157.95, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 149.01, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 174.84, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 115.23, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 108.48, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AMPICILLIN 500 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00781214501", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", 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Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": 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"standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AMPICILLIN SODIUM 1 G IJ SOLR", "drug_information": { "unit": "4.000000", "type": "UN" }, "code_information": [ { "code": "00781340495", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": 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"standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AMPICILLIN SODIUM 100 MG/ML IJ 500 MG VIAL (RECON)", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "00781340795", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", 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"Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AMPICILLIN SODIUM 2 G IJ SOLR", "drug_information": { "unit": "8.000000", "type": "UN" }, "code_information": [ { "code": "72485042210", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AMPICILLIN SODIUM 250 MG IJ SOLR", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00781340295", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AMPICILLIN SODIUM 500 MG IJ SOLR", "drug_information": { "unit": "2.000000", "type": "UN" }, "code_information": [ { "code": "00781340795_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AMPICILLIN SUBCONJUNCTIVAL INJ (125 MG/0.5 ML)", "drug_information": { "unit": "0.500000", "type": "UN" }, "code_information": [ { "code": "08252001500", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AMPICILLIN-SULBACTAM SODIUM 1.5 (1-0.5) G IJ SOLR", "drug_information": { "unit": "4.000000", "type": "UN" }, "code_information": [ { "code": "25021014220", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AMPICILLIN-SULBACTAM SODIUM 15 (10-5) G IV SOLR", "drug_information": { "unit": "100.000000", "type": "UN" }, "code_information": [ { "code": "55150011899", "type": "NDC" } ], "standard_charges": [ { "minimum": 50.39, "maximum": 168.07, "gross_charge": 178.8, "discounted_cash": 98.34, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.7, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 97.62, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 143.04, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 151.44, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.03, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 85.82, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 107.1, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 106.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 168.07, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 157.34, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.39, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 151.98, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 134.1, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 62.99, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 121.58, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 168.07, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 140.0, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 97.62, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 142.15, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 134.1, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 157.34, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.7, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 97.62, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IJ SOLR", "drug_information": { "unit": "8.000000", "type": "UN" }, "code_information": [ { "code": "55150011720", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Amputate lower leg at knee", "code_information": [ { "code": "27598", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 24436.54, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 44340.52, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 44340.52, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Amputate metacarpal bone", "code_information": [ { "code": "26910", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2391.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1771.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 7262.93, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 13178.7, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2391.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 13178.7, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Amputation follow-up surgery", "code_information": [ { "code": "25909", "type": "HCPCS" }, { "code": "25931", "type": "HCPCS" }, { "code": "27884", "type": "HCPCS" }, { "code": "27886", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 5265.64, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3900.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1771.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 13888.24, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 25200.45, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5265.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2391.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 25200.45, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Amputation of finger/thumb", "code_information": [ { "code": "26951", "type": "HCPCS" }, { "code": "26952", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2391.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1771.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 9204.18, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 16701.13, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2391.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 16701.13, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Amputation of foot at ankle", "code_information": [ { "code": "27889", "type": "HCPCS" }, { "code": "27888", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 5265.64, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3900.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 21587.94, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 40153.87, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5265.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 40153.87, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Amputation of forearm", "code_information": [ { "code": "25905", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 16780.75, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 30448.93, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 30448.93, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Amputation of toe", "code_information": [ { "code": "28820", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2391.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1771.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 8113.08, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 14721.3, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2391.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 14721.3, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Amputation thru metatarsal", "code_information": [ { "code": "28805", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2391.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1771.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 16256.61, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 29497.87, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2391.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 29497.87, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Amputation toe & metatarsal", "code_information": [ { "code": "28810", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2391.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1771.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 9034.15, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 16392.6, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2391.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 16392.6, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ANAGRELIDE HCL 0.5 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "13668045301", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ANAGRELIDE HCL 1 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "13668046201", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ANAKINRA 100 MG/0.67ML IV SOSY", "drug_information": { "unit": "0.670000", "type": "UN" }, "code_information": [ { "code": "66658023407", "type": "NDC" } ], "standard_charges": [ { "minimum": 194.2, "maximum": 1158.0, "gross_charge": 689.15, "discounted_cash": 379.03, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 399.71, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 376.28, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 598.18, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 200.54, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 330.79, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 412.8, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 412.11, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 647.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 606.45, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 194.2, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 585.78, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 516.86, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 242.79, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 468.62, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 647.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 539.6, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 376.28, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 547.87, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 516.86, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 606.45, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 399.71, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 376.28, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ANAKINRA 100 MG/0.67ML SC SOSY", "drug_information": { "unit": "0.670000", "type": "UN" }, "code_information": [ { "code": "66658023407_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 194.2, "maximum": 647.8, "gross_charge": 689.15, "discounted_cash": 379.03, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 399.71, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 376.28, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 551.32, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 583.71, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 200.54, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 330.79, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 412.8, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 412.11, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 647.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 606.45, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 194.2, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 585.78, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 516.86, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 242.79, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 468.62, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 647.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 539.6, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 376.28, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 547.87, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 516.86, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 606.45, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 399.71, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 376.28, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Anal sp inf pmp w/reprg&fill", "code_information": [ { "code": "62369", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 221.06, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 163.75, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 1993.92, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 3618.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 221.06, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 3618.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ANALGESIC BALM 10-15 % EX CREA", "drug_information": { "unit": "85.000000", "type": "GR" }, "code_information": [ { "code": "41167006003", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.38, "maximum": 4.61, "gross_charge": 4.9, "discounted_cash": 2.7, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.84, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.68, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.92, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.15, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.43, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.35, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.94, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.93, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.61, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.31, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.38, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.68, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.73, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.33, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.61, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.84, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.68, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.9, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.68, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.31, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.84, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.68, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Analyze sp inf pump w/reprog", "code_information": [ { "code": "62368", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 221.06, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 684.48, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 1242.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 221.06, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 1242.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Analyze spine infus pump", "code_information": [ { "code": "62367", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 221.06, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 1235.04, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 2241.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 221.06, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 2241.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ANASTROZOLE 1 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687011221", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ANGIOTENSIN II ACETATE 2.5 MG/ML IV SOLN", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68547050102", "type": "NDC" } ], "standard_charges": [ { "minimum": 1369.55, "maximum": 4568.4, "gross_charge": 4860.0, "discounted_cash": 2673.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2818.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2653.56, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3888.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4116.42, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1414.26, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2332.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2911.14, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2906.28, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4568.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4276.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1369.55, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4131.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3645.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1712.18, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3304.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4568.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3805.38, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2653.56, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3863.7, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3645.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4276.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2818.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2653.56, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ANIDULAFUNGIN 100 MG IV SOLR", "drug_information": { "unit": "30.000000", "type": "UN" }, "code_information": [ { "code": "00049011628", "type": "NDC" } ], "standard_charges": [ { "minimum": 66.49, "maximum": 221.79, "gross_charge": 235.95, "discounted_cash": 129.77, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 136.85, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 128.83, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 188.76, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 199.85, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 68.66, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 113.26, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 141.33, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 141.1, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 221.79, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 207.64, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 66.49, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 200.56, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 176.96, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 83.13, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 160.45, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 221.79, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 184.75, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 128.83, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 187.58, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 176.96, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 207.64, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 136.85, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 128.83, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ANIDULAFUNGIN 50 MG IV SOLR", "drug_information": { "unit": "15.000000", "type": "UN" }, "code_information": [ { "code": "00049011428", "type": "NDC" } ], "standard_charges": [ { "minimum": 27.7, "maximum": 92.4, "gross_charge": 98.3, "discounted_cash": 54.07, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 57.01, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 53.67, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 78.64, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 83.26, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.61, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.18, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 58.88, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 58.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 92.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.5, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.7, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 83.56, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 73.73, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.63, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 66.84, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 92.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 76.97, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 53.67, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 78.15, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 73.73, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.5, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 57.01, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 53.67, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Ankle arthroscopy/surgery", "code_information": [ { "code": "29891", "type": "HCPCS" }, { "code": "29892", "type": "HCPCS" }, { "code": "29894", "type": "HCPCS" }, { "code": "29895", "type": "HCPCS" }, { "code": "29897", "type": "HCPCS" }, { "code": "29898", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 5265.64, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1771.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3900.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 18359.55, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 33313.7, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2391.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5265.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 33313.7, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Anl sp inf pmp w/mdreprg&fil", "code_information": [ { "code": "62370", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 221.06, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 163.75, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 2055.15, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 3729.11, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 221.06, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 3729.11, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Anoscopy", "code_information": [ { "code": "46615", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2021.42, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1497.34, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 7121.19, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 12921.56, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2021.42, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 12921.56, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Anoscopy and biopsy", "code_information": [ { "code": "46606", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 869.1, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 643.78, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 6155.47, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 11169.2, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 869.1, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 11169.2, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Anoscopy remove lesion", "code_information": [ { "code": "46610", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2021.42, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1497.34, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 4612.8, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 8370.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2021.42, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 8370.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Antepartum manipulation", "code_information": [ { "code": "59412", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2343.63, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1736.02, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 3972.96, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 7209.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2343.63, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 7209.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Anterior colporrhaphy", "code_information": [ { "code": "57240", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 3638.66, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2695.3, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 13937.85, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 25290.47, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3638.66, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 25290.47, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ANTI-THYMOCYTE GLOB (RABBIT) 25 MG IV SOLR", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "58468008001", "type": "NDC" } ], "standard_charges": [ { "minimum": 522.38, "maximum": 2605.68, "gross_charge": 2772.0, "discounted_cash": 1524.6, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1607.76, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 522.38, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2217.6, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2347.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 806.65, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1330.56, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1660.43, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 1657.66, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2605.68, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2439.36, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 781.15, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2356.2, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2079.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 976.58, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1884.96, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2605.68, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2170.48, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 705.21, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2203.74, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2079.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2439.36, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1607.76, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 522.38, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "ANTI-THYMOCYTE GLOB (RABBIT) 25 MG IV SOLR (MIXTURE USE)", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "58468008001_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 522.38, "maximum": 2605.68, "gross_charge": 2772.0, "discounted_cash": 1524.6, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1607.76, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 522.38, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2217.6, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2347.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 806.65, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1330.56, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1660.43, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 1657.66, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2605.68, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2439.36, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 781.15, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2356.2, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2079.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 976.58, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1884.96, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2605.68, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2170.48, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 705.21, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2203.74, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2079.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2439.36, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1607.76, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 522.38, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "ANTICOAGULANT SODIUM CITRATE 46.7 % VI CONC", "drug_information": { "unit": "30.000000", "type": "UN" }, "code_information": [ { "code": "23731603003", "type": "NDC" } ], "standard_charges": [ { "minimum": 84.54, "maximum": 1158.0, "gross_charge": 300.0, "discounted_cash": 165.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 174.0, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 163.8, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 260.4, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.3, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 144.0, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 179.7, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 179.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 282.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 264.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 84.54, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 255.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 225.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 105.69, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 204.0, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 282.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 234.9, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 163.8, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 238.5, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 225.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 264.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 174.0, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 163.8, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ANTIHEM FACTOR RECOMB (RFVIII) 1000 UNITS IV KIT", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00026378555_3", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.85, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.85, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.14, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.85, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "ANTIHEM FACTOR RECOMB (RFVIII) 1000 UNITS IV KIT|DISCARDED DRUG NOT ADMINISTERED", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00026378555", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.66, "maximum": 2.19, "gross_charge": 2.33, "discounted_cash": 1.28, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.35, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.85, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.86, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.97, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.68, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.12, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.19, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.05, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.66, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.98, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.82, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.58, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.19, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.82, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.14, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.85, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.05, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.35, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.85, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "ANTIHEM FACTOR RECOMB (RFVIII) 801-1240 UNITS IV SOLR", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00944284310_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.85, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.85, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 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"HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.85, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "ANTIHEM FACTOR RECOMB (RFVIII) 801-1240 UNITS IV SOLR|DISCARDED DRUG NOT ADMINISTERED", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00944284310", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.85, "maximum": 2.85, "gross_charge": 3.03, "discounted_cash": 1.67, "setting": "inpatient", "payers_information": [ { 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"standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.85, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.58, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.27, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.07, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", 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{ "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.27, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.67, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.76, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.85, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "ANTIHEMOPHIL FACTOR (RAHF-PFM) 2000 UNITS IV SOLR", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00944304510_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.85, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.85, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.14, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.85, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "ANTIHEMOPHIL FACTOR (RAHF-PFM) 2000 UNITS IV SOLR|DISCARDED DRUG NOT ADMINISTERED", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00944304510", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.85, "maximum": 2.86, "gross_charge": 3.04, "discounted_cash": 1.67, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.76, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.85, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.43, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.57, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.88, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.46, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.82, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.82, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.86, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.68, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.86, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.58, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.28, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.07, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.07, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.86, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.38, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.14, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.42, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.28, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.68, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.76, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.85, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "ANTIHEMOPHIL FACTOR (RAHF-PFM) 500 UNITS IV SOLR", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00944305202_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.85, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.85, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.14, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.85, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "ANTIHEMOPHIL FACTOR (RAHF-PFM) 500 UNITS IV SOLR|DISCARDED DRUG NOT ADMINISTERED", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00944305202", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.74, "maximum": 2.47, "gross_charge": 2.63, "discounted_cash": 1.45, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.53, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.85, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.1, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.23, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.77, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.26, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.58, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.57, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.47, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.31, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.74, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.24, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.97, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.93, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.79, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.47, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.06, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.14, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.09, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.97, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.31, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.53, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.85, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "ANTIHEMOPHILIC FACTOR 1000 UNITS IV SOLR", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00944394402_3", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.64, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.86, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "ANTIHEMOPHILIC FACTOR 1000 UNITS IV SOLR|DISCARDED DRUG NOT ADMINISTERED", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00944394402", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.64, "maximum": 2.9, "gross_charge": 3.08, "discounted_cash": 1.69, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.79, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.46, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.61, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.9, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.48, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.84, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.84, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.9, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.71, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.87, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.62, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.31, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.09, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.9, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.41, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.86, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.31, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.71, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.79, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "ANTIHEMOPHILIC FACTOR 1700 UNITS IV SOLR", "drug_information": { "unit": "1.000000", "type": "F2" }, "code_information": [ { "code": "00944394602_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.64, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, 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88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "ANTIHEMOPHILIC FACTOR 1700 UNITS IV SOLR|DISCARDED DRUG NOT ADMINISTERED", "drug_information": { "unit": "1.000000", "type": "F2" }, "code_information": [ { "code": "00944394602", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.55, "maximum": 1.82, "gross_charge": 1.94, "discounted_cash": 1.07, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 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"N/A", "standard_charge_dollar": 0.93, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.82, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.71, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.55, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.65, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.46, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.68, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.32, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.82, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.52, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.86, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.54, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.46, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.71, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "ANTIHEMOPHILIC FACTOR RAHF-PAF (XYNTHA)", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "58394001401_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ANTIHEMOPHILIC FACTOR RAHF-PAF (XYNTHA)|DISCARDED DRUG NOT ADMINISTERED", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "58394001401", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.6, "maximum": 2.0, "gross_charge": 2.13, "discounted_cash": 1.17, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.24, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.7, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.8, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.62, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.02, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.28, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.27, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.87, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.6, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.81, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.6, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.45, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.67, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.69, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.6, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.87, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.24, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ANTIHEMOPHILIC FACTOR VIII (KOATE DVI)", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00944394402_4", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.64, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.86, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "ANTIHEMOPHILIC FACTOR VIII (KOATE DVI)|DISCARDED DRUG NOT ADMINISTERED", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00944394402_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.64, "maximum": 2.9, "gross_charge": 3.08, "discounted_cash": 1.69, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.79, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.46, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.61, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.9, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.48, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.84, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.84, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.9, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.71, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.87, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.62, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.31, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.09, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.9, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.41, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.86, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.31, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.71, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.79, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "ANTIHEMOPHILIC FACTOR VIII RECOMBINANT (ADVATE)", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00944305302_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.85, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.85, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.14, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.85, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "ANTIHEMOPHILIC FACTOR VIII RECOMBINANT (ADVATE)|DISCARDED DRUG NOT ADMINISTERED", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00944305302", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.85, "maximum": 3.06, "gross_charge": 3.26, "discounted_cash": 1.79, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.89, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.85, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.61, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.76, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.95, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.56, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.95, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.95, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.06, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.87, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.92, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.77, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.45, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.15, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.22, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.06, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.55, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.14, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.59, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.45, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.87, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.89, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.85, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "ANTIHEMOPHILIC FACTOR VIII RECOMBINANT (KOGENATE FS)", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00026378555_4", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.85, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.85, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.14, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.85, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "ANTIHEMOPHILIC FACTOR VIII RECOMBINANT (KOGENATE FS)|DISCARDED DRUG NOT ADMINISTERED", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00026378555_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.66, "maximum": 2.19, "gross_charge": 2.33, "discounted_cash": 1.28, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.35, "standard_charge_percentage": 58.0, "methodology": 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"standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.19, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.05, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.66, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.98, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.82, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.58, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.19, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.82, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.14, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.85, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.05, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.35, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.85, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "ANTIHEMOPHILIC FACTOR-FVIII (ALPHANATE) IV SYRINGE", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68516461802_6", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.67, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.67, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.91, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.67, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "ANTIHEMOPHILIC FACTOR-FVIII (ALPHANATE) IV SYRINGE|DISCARDED DRUG NOT ADMINISTERED", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68516461802", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.62, "maximum": 2.07, "gross_charge": 2.2, "discounted_cash": 1.21, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.28, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.67, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.76, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.86, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.06, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.32, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.32, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.07, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.94, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.62, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.87, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.65, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.78, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.5, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.07, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.72, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.91, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.75, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.65, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.94, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.28, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.67, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "ANTIHEMOPHILIC FACTOR-VWF (ALPHANATE)", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68516461802_7", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.67, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.67, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.91, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.67, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "ANTIHEMOPHILIC FACTOR-VWF (ALPHANATE) IV SYRINGE", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68516461802_8", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.67, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.67, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.91, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.67, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "ANTIHEMOPHILIC FACTOR-VWF (ALPHANATE) IV SYRINGE|DISCARDED DRUG NOT ADMINISTERED", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68516461802_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.62, "maximum": 2.07, "gross_charge": 2.2, "discounted_cash": 1.21, "setting": "inpatient", 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"standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.06, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.32, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.32, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.07, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.94, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.62, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.87, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.65, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.78, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.5, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.07, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.72, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.91, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.75, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.65, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.94, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.28, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.67, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "ANTIHEMOPHILIC FACTOR-VWF (ALPHANATE)|DISCARDED DRUG NOT ADMINISTERED", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68516461802_3", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.62, "maximum": 2.07, "gross_charge": 2.2, "discounted_cash": 1.21, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.28, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.67, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.76, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.86, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.06, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.32, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.32, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.07, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.94, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.62, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.87, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.65, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.78, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.5, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.07, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.72, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.91, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.75, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.65, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.94, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.28, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.67, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "ANTIHEMOPHILIC FACTOR-VWF 1000 UNITS IV SOLR", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68516461802_5", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.67, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.67, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.91, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.67, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "ANTIHEMOPHILIC FACTOR-VWF 1000 UNITS IV SOLR|DISCARDED DRUG NOT ADMINISTERED", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68516461802_4", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.62, "maximum": 2.07, "gross_charge": 2.2, "discounted_cash": 1.21, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.28, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.67, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.76, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.86, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.06, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.32, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.32, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.07, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.94, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.62, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.87, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.65, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.78, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.5, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", 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"standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.03, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.76, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "ANTIHEMOPHILIC FACTOR-VWF 250-600 UNITS IV SOLR|DISCARDED DRUG NOT ADMINISTERED", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "63833061502", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.75, "maximum": 2.5, "gross_charge": 2.66, "discounted_cash": 1.46, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.54, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.76, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.13, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.25, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.77, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.28, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.59, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.59, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.5, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.34, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.26, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.94, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.81, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.5, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.08, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.03, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.11, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.34, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.54, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.76, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "ANTIHEMOPHILIC FACTOR-VWF 500 UNITS IV SOLR", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68516461701_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.67, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.67, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.91, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.67, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "ANTIHEMOPHILIC FACTOR-VWF 500 UNITS IV SOLR|DISCARDED DRUG NOT ADMINISTERED", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68516461701", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.58, "maximum": 1.95, "gross_charge": 2.07, "discounted_cash": 1.14, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.67, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.66, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.75, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.6, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.99, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.24, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.24, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.95, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.82, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.58, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.76, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.55, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.73, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", 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"percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": 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charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.76, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "ANTIHEMOPHILIC FACTOR-VWF 500-1200 UNITS IV SOLR|DISCARDED DRUG NOT ADMINISTERED", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "63833061602", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.59, "maximum": 1.96, "gross_charge": 2.08, "discounted_cash": 1.14, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.21, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.76, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.66, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.76, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.61, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.0, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.25, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.24, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.96, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.83, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.59, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.77, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.56, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.73, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.96, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.63, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.03, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.65, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.56, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.83, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.21, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.76, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "ANTIINHIBITOR COAGULANT CMPLX 1000 UNITS IV SOLR", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "64193042402_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.28, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.72, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "ANTIINHIBITOR COAGULANT CMPLX 1000 UNITS IV SOLR|DISCARDED DRUG NOT ADMINISTERED", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "64193042402", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.19, "maximum": 3.98, "gross_charge": 4.23, "discounted_cash": 2.33, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.45, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.38, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.58, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.23, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.03, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.53, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.53, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.98, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.72, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.19, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.6, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.17, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.49, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.88, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.98, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.31, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.72, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.36, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.17, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.72, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.45, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "ANTIINHIBITOR COAGULANT CMPLX 2500 UNITS IV SOLR", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "64193042502_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.28, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.72, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "ANTIINHIBITOR COAGULANT CMPLX 2500 UNITS IV SOLR|DISCARDED DRUG NOT ADMINISTERED", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "64193042502", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.11, "maximum": 3.69, "gross_charge": 3.93, "discounted_cash": 2.16, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.28, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.14, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.33, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.14, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.89, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.35, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.35, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.69, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.46, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.11, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.34, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.95, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.38, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.67, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.69, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.08, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.72, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.12, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.95, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.46, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.28, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "ANTITHROMBIN III HUMAN (THROMBATE III)", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "13533060612_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.1, "maximum": 4590.2, "gross_charge": 4883.19, "discounted_cash": 2685.75, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2832.25, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.1, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3906.55, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4136.06, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1421.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2343.93, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2925.03, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2920.15, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4590.2, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4297.21, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1376.08, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4150.71, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3662.39, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1720.35, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3320.57, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4590.2, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3823.54, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.84, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3882.14, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3662.39, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4297.21, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2832.25, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.1, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "ANTITHROMBIN III HUMAN (THROMBATE III)|DISCARDED DRUG NOT ADMINISTERED", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "13533060612", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.1, "maximum": 4524.4, "gross_charge": 4813.19, "discounted_cash": 2647.25, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2791.65, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.1, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3850.55, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4076.77, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1400.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2310.33, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2883.1, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2878.29, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4524.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4235.61, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1356.36, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4091.21, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3609.89, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1695.69, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3272.97, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4524.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3768.73, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.84, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3826.49, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3609.89, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4235.61, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2791.65, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.1, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "ANTITHYMOCYTE GLOBULIN (RABBIT) SKIN TEST", "drug_information": { "unit": "0.100000", "type": "UN" }, "code_information": [ { "code": "58468008001_3", "type": "NDC" } ], "standard_charges": [ { "minimum": 522.38, "maximum": 2605.68, "gross_charge": 2772.0, "discounted_cash": 1524.6, 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"additional_payer_notes": "N/A", "standard_charge_dollar": 2439.36, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 781.15, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2356.2, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2079.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 976.58, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1884.96, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2605.68, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2170.48, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 705.21, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 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(RABBIT) SKIN TEST (1:10 DILUTION) VIAL", "drug_information": { "unit": "0.100000", "type": "UN" }, "code_information": [ { "code": "58468008001_4", "type": "NDC" } ], "standard_charges": [ { "minimum": 522.38, "maximum": 2605.68, "gross_charge": 2772.0, "discounted_cash": 1524.6, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1607.76, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 522.38, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2217.6, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { 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"payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 705.21, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2203.74, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2079.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2439.36, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1607.76, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 522.38, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "ANTITHYMOCYTE GLOBULIN (RABBIT) SKIN TEST (1:100 DILUTION) VIAL", "drug_information": { "unit": "0.100000", "type": "UN" }, "code_information": [ { "code": "58468008001_5", "type": "NDC" } ], "standard_charges": [ { "minimum": 522.38, "maximum": 2605.68, "gross_charge": 2772.0, "discounted_cash": 1524.6, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1607.76, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 522.38, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2217.6, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2347.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 806.65, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1330.56, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1660.43, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 1657.66, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2605.68, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2439.36, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 781.15, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2356.2, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2079.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 976.58, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1884.96, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2605.68, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2170.48, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 705.21, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2203.74, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2079.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2439.36, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1607.76, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 522.38, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "ANTIVENIN LATRODECTUS MACTANS IJ KIT", "drug_information": { "unit": "2.500000", "type": "UN" }, "code_information": [ { "code": "00006542402", "type": "NDC" } ], "standard_charges": [ { "minimum": 19.52, "maximum": 1158.0, "gross_charge": 69.28, "discounted_cash": 38.1, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.18, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.83, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.14, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.25, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.5, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.43, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.12, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.97, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.52, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 58.89, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 51.96, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.11, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.12, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.25, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.83, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.08, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 51.96, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.97, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.18, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.83, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "APIXABAN 2.5 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00003089331", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "APIXABAN 5 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00003089431", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Appendectomy", "code_information": [ { "code": "44950", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4599.32, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3406.9, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 17403.83, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 31579.58, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4599.32, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 31579.58, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Appl mltpln uni ext fixj sys", "code_information": [ { "code": "20692", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 9484.13, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 7025.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 10741.2, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 19490.08, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 9484.13, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 19490.08, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Appl unipln uni ext fixj sys", "code_information": [ { "code": "20690", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 5265.64, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3900.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 18416.71, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 33417.43, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5265.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 33417.43, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "APRACLONIDINE HCL 0.5 % OP SOLN", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "61314066505", "type": "NDC" } ], "standard_charges": [ { "minimum": 26.75, "maximum": 89.23, "gross_charge": 94.93, "discounted_cash": 52.21, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.06, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 51.83, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.94, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 80.41, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.62, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.57, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 56.86, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 56.77, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 89.23, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 83.54, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.75, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 80.69, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 71.2, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.44, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 64.55, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 89.23, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.33, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 51.83, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.47, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 71.2, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 83.54, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.06, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 51.83, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "APRACLONIDINE HCL 1 % OP SOLN", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "82667020001", "type": "NDC" } ], "standard_charges": [ { "minimum": 42.46, "maximum": 141.64, "gross_charge": 150.68, "discounted_cash": 82.87, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.39, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.27, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 120.54, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 127.63, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.85, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 72.33, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 90.26, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 90.11, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 141.64, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 132.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.46, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 128.08, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 113.01, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 53.08, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 102.46, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 141.64, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 117.98, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.27, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 119.79, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 113.01, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 132.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.39, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.27, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "APREPITANT 125 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00781232368", "type": "NDC" } ], "standard_charges": [ { "minimum": 161.64, "maximum": 539.17, "gross_charge": 573.59, "discounted_cash": 315.47, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 332.68, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 313.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 458.87, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 485.83, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 166.91, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 275.32, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 343.58, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 343.01, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 539.17, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 504.76, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 161.64, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 487.55, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 430.19, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 202.08, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 390.04, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 539.17, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 449.12, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 313.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 456.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 430.19, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 504.76, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 332.68, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 313.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "APREPITANT 40 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00781232151", "type": "NDC" } ], "standard_charges": [ { "minimum": 56.82, "maximum": 189.53, "gross_charge": 201.63, "discounted_cash": 110.9, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 116.95, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 110.09, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 161.3, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 170.78, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 58.67, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.78, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 120.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 120.57, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 189.53, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 177.43, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 56.82, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 171.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 151.22, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 71.03, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 137.11, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 189.53, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 157.88, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 110.09, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 160.3, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 151.22, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 177.43, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 116.95, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 110.09, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "APREPITANT 80 & 125 MG PO MISC", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00006386203", "type": "NDC" } ], "standard_charges": [ { "minimum": 691.69, "maximum": 2307.28, "gross_charge": 2454.55, "discounted_cash": 1350.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1423.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1340.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1963.64, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2079.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 714.27, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1178.18, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1470.28, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 1467.82, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2307.28, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2160.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 691.69, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2086.37, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1840.91, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 864.74, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1669.09, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2307.28, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1921.91, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1340.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1951.37, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1840.91, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2160.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1423.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1340.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "APREPITANT 80 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00781232268", "type": "NDC" } ], "standard_charges": [ { "minimum": 122.86, "maximum": 409.83, "gross_charge": 435.99, "discounted_cash": 239.79, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 252.87, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 238.05, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 348.79, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 369.28, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 126.87, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 209.28, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 261.16, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 260.72, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 409.83, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 383.67, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 122.86, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 370.59, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 326.99, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 153.6, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 296.47, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 409.83, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 341.38, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 238.05, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 346.61, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 326.99, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 383.67, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 252.87, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 238.05, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AQUADEKS PO CHEW", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "R5891401460", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AQUADEKS PO SOLN", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "58204000404", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AQUANIL SKIN CLEANSER EX LOTN", "drug_information": { "unit": "480.000000", "type": "UN" }, "code_information": [ { "code": "00096072416", "type": "NDC" } ], "standard_charges": [ { "minimum": 7.67, "maximum": 25.6, "gross_charge": 27.23, "discounted_cash": 14.98, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.79, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.87, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.78, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.06, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.92, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.07, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.31, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.28, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.67, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.15, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.42, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.59, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.52, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.87, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.65, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.42, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.79, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.87, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AQUAPHOR ADVANCED THERAPY EX OINT", "drug_information": { "unit": "396.000000", "type": "GR" }, "code_information": [ { "code": "72140063608", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.48, "maximum": 38.31, "gross_charge": 40.75, "discounted_cash": 22.41, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.25, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.6, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.52, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.86, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.56, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.41, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.37, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.31, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.86, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.48, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.64, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.56, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.36, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.71, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.31, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.91, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.25, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.4, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.56, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.86, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.25, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AQUAPHOR EX OINT", "drug_information": { "unit": "50.000000", "type": "GR" }, "code_information": [ { "code": "72140045231", "type": "NDC" } ], "standard_charges": [ { "minimum": 3.81, "maximum": 12.72, "gross_charge": 13.53, "discounted_cash": 7.44, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.85, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.39, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.82, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.46, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.94, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.49, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.1, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.09, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.72, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.91, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.81, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.15, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.77, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.72, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.59, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.39, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.76, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.15, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.91, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.85, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.39, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Aqueous shunt eye w/graft", "code_information": [ { "code": "66180", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 3803.22, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2817.2, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 8866.08, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 16087.64, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3803.22, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 16087.64, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Aqueous shunt eye w/o graft", "code_information": [ { "code": "66179", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 3803.22, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2817.2, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 3868.25, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 7019.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3803.22, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 7019.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ARFORMOTEROL TARTRATE 15 MCG/2ML IN NEBU", "drug_information": { "unit": "2.000000", "type": "UN" }, "code_information": [ { "code": "69097016864", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ARGATROBAN 250 MG/2.5ML IV SOLN", "drug_information": { "unit": "2.500000", "type": "UN" }, "code_information": [ { "code": "00143967401", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.69, "maximum": 566.18, "gross_charge": 602.32, "discounted_cash": 331.28, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 349.35, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.69, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 481.86, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 510.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 175.28, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 289.11, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 360.79, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 360.19, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 566.18, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 530.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 169.73, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 511.97, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 451.74, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 212.2, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 409.58, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 566.18, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 471.62, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.93, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 478.84, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 451.74, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 530.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 349.35, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.69, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "ARGATROBAN 250 MG/250 ML DRIP (STRAIGHT DRUG) (MULTI-GPI)", "drug_information": { "unit": "250.000000", "type": "UN" }, "code_information": [ { "code": "00000198801", "type": "NDC" } ], "standard_charges": [ { "minimum": 613.31, "maximum": 2045.82, "gross_charge": 2176.4, "discounted_cash": 1197.02, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1262.31, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1188.31, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1741.12, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1843.41, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 633.33, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1044.67, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1303.66, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 1301.49, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2045.82, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1915.23, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 613.31, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1849.94, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1632.3, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 766.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1479.95, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2045.82, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1704.12, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1188.31, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1730.24, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1632.3, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1915.23, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1262.31, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1188.31, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ARGATROBAN 50 MG/50ML IV SOLN", "drug_information": { "unit": "50.000000", "type": "UN" }, "code_information": [ { "code": "25021041450", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.69, "maximum": 197.06, "gross_charge": 209.64, "discounted_cash": 115.3, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 121.59, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.69, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 167.71, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 177.57, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 100.63, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 125.57, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 125.36, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 197.06, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 184.48, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.08, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 178.19, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 157.23, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 73.86, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 142.56, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 197.06, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 164.15, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.93, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 166.66, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 157.23, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 184.48, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 121.59, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.69, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "ARGATROBAN 50 MG/50ML IV SOLN (MULTI-GPI)", "drug_information": { "unit": "50.000000", "type": "UN" }, "code_information": [ { "code": "65219042950", "type": "NDC" } ], "standard_charges": [ { "minimum": 107.6, "maximum": 358.91, "gross_charge": 381.82, "discounted_cash": 210.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 221.46, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 208.47, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 305.46, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 323.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 111.11, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 183.27, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 228.71, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 228.33, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 358.91, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 336.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 107.6, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 324.55, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 286.37, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 134.52, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 259.64, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 358.91, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 298.97, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 208.47, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 303.55, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 286.37, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 336.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 221.46, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 208.47, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ARGININE 10% (FOR AMMONUL PANEL) LOADING DOSE", "drug_information": { "unit": "300.000000", "type": "UN" }, "code_information": [ { "code": "00009043601_3", "type": "NDC" } ], "standard_charges": [ { "minimum": 46.47, "maximum": 1158.0, "gross_charge": 164.9, "discounted_cash": 90.7, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 95.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 90.04, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 143.13, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.99, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 79.15, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 98.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 98.61, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 155.01, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 145.11, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.47, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 140.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 123.68, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 58.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 112.13, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 155.01, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 129.12, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 90.04, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 131.1, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 123.68, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 145.11, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 95.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 90.04, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ARGININE 10% (FOR AMMONUL PANEL) MAINTENANCE INFUSION", "drug_information": { "unit": "300.000000", "type": "UN" }, "code_information": [ { "code": "00009043601_4", "type": "NDC" } ], "standard_charges": [ { "minimum": 46.47, "maximum": 1158.0, "gross_charge": 164.9, "discounted_cash": 90.7, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 95.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 90.04, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 143.13, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.99, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 79.15, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 98.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 98.61, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 155.01, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 145.11, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.47, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 140.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 123.68, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 58.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 112.13, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 155.01, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 129.12, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 90.04, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 131.1, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 123.68, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 145.11, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 95.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 90.04, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ARGININE HCL (DIAGNOSTIC) 10 % IV SOLN", "drug_information": { "unit": "300.000000", "type": "UN" }, "code_information": [ { "code": "00009043601", "type": "NDC" } ], "standard_charges": [ { "minimum": 28.18, "maximum": 1158.0, "gross_charge": 100.0, "discounted_cash": 55.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 58.0, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.6, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.8, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.1, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 48.0, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.9, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.8, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 94.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.18, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 85.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.23, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 68.0, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 94.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 78.3, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.6, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 79.5, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 58.0, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.6, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ARGININE HCL 10 % (IV FOR PO)", "drug_information": { "unit": "300.000000", "type": "UN" }, "code_information": [ { "code": "00009043601_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 28.18, "maximum": 1158.0, "gross_charge": 100.0, "discounted_cash": 55.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 58.0, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.6, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.8, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.1, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 48.0, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.9, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.8, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 94.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.18, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 85.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.23, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 68.0, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 94.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 78.3, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.6, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 79.5, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 58.0, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.6, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ARGININE HCL 10% IV SYRINGE (PEDS)", "drug_information": { "unit": "300.000000", "type": "UN" }, "code_information": [ { "code": "00009043601_5", "type": "NDC" } ], "standard_charges": [ { "minimum": 46.47, "maximum": 1158.0, "gross_charge": 164.9, "discounted_cash": 90.7, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 95.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 90.04, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 143.13, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.99, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 79.15, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 98.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 98.61, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 155.01, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 145.11, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.47, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 140.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 123.68, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 58.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 112.13, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 155.01, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 129.12, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 90.04, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 131.1, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 123.68, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 145.11, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 95.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 90.04, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ARGININE HCL 1MEQ/ML ORAL SOLUTION", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "P0009043624", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 1158.0, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.47, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ARIPIPRAZOLE 1 MG/ML PO SOLN", "drug_information": { "unit": "2.000000", "type": "UN" }, "code_information": [ { "code": "66689073505", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.28, "maximum": 4.26, "gross_charge": 4.53, "discounted_cash": 2.49, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.63, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.47, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.62, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.84, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.32, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.17, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.71, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.71, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.26, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.99, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.28, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.85, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.6, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.08, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.26, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.55, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.47, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.6, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.99, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.63, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.47, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ARIPIPRAZOLE 10 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "50268008915", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ARIPIPRAZOLE 10 MG PO TBDP", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "43598073330", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.74, "maximum": 9.15, "gross_charge": 9.73, "discounted_cash": 5.35, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.31, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.78, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.24, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.83, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.67, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.83, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.82, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.15, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.56, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.74, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.27, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.3, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.43, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.62, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.15, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.62, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.31, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.74, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.3, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.56, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.31, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ARIPIPRAZOLE 15 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "50268009012", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ARIPIPRAZOLE 15 MG PO TBDP", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "43598073430", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.74, "maximum": 9.15, "gross_charge": 9.73, "discounted_cash": 5.35, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.31, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.78, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.24, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.83, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.67, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.83, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.82, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.15, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.56, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.74, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.27, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.3, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.43, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.62, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.15, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.62, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.31, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.74, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.3, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.56, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.31, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ARIPIPRAZOLE 2 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687015721", "type": "NDC" } ], "standard_charges": [ { "minimum": 3.13, "maximum": 10.43, "gross_charge": 11.1, "discounted_cash": 6.11, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.44, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.88, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.23, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.33, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.65, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.64, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.43, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.77, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.44, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.33, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.91, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.55, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.43, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.69, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.82, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.33, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.77, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.44, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ARIPIPRAZOLE 20 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687020221", "type": "NDC" } ], "standard_charges": [ { "minimum": 4.24, "maximum": 14.15, "gross_charge": 15.05, "discounted_cash": 8.28, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.73, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.04, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.75, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.38, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.22, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.01, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.0, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.15, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.24, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.24, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.79, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.29, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.3, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.23, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.15, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.78, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.96, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.29, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.24, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.73, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ARIPIPRAZOLE 30 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687021321", "type": "NDC" } ], "standard_charges": [ { "minimum": 4.44, "maximum": 14.82, "gross_charge": 15.77, "discounted_cash": 8.67, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.15, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.61, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.62, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.36, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.59, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.57, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.45, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.43, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.82, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.88, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.44, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.83, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.56, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.82, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.35, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.61, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.54, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.83, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.88, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.15, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.61, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ARIPIPRAZOLE 5 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "50268008815", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ARIPIPRAZOLE ER 300 MG IM PRSY", "drug_information": { "unit": "1.500000", "type": "UN" }, "code_information": [ { "code": "59148004580", "type": "NDC" } ], "standard_charges": [ { "minimum": 3.86, "maximum": 5185.5, "gross_charge": 5516.49, "discounted_cash": 3034.07, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3199.56, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.86, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4413.19, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4672.47, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1605.3, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2647.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3304.38, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 3298.86, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5185.5, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4854.51, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1554.55, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4689.02, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4137.37, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1943.46, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3751.21, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5185.5, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4319.41, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.21, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4385.61, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4137.37, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4854.51, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3199.56, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.86, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "ARIPIPRAZOLE ER 400 MG IM PRSY", "drug_information": { "unit": "400.000000", "type": "ME" }, "code_information": [ { "code": "59148007280", "type": "NDC" } ], "standard_charges": [ { "minimum": 3.86, "maximum": 6914.02, "gross_charge": 7355.34, "discounted_cash": 4045.44, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4266.1, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.86, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5884.27, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6229.97, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2140.4, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3530.56, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4405.85, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4398.49, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6914.02, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6472.7, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2072.73, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6252.04, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5516.51, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2591.29, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5001.63, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6914.02, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5759.23, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.21, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5847.5, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5516.51, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6472.7, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4266.1, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.86, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "ARIPIPRAZOLE ER 400 MG IM SRER", "drug_information": { "unit": "2.000000", "type": "UN" }, "code_information": [ { "code": "59148001971", "type": "NDC" } ], "standard_charges": [ { "minimum": 2072.73, "maximum": 6914.02, "gross_charge": 7355.34, "discounted_cash": 4045.44, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4266.1, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4016.02, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5884.27, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6229.97, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2140.4, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3530.56, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4405.85, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4398.49, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6914.02, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6472.7, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2072.73, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6252.04, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5516.51, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2591.29, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5001.63, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6914.02, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5759.23, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4016.02, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5847.5, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5516.51, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6472.7, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4266.1, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4016.02, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ARIPIPRAZOLE LAUROXIL ER 1064 MG/3.9ML IM PRSY", "drug_information": { "unit": "3.900000", "type": "UN" }, "code_information": [ { "code": "65757040403", "type": "NDC" } ], "standard_charges": [ { "minimum": 2853.55, "maximum": 9518.57, "gross_charge": 10126.14, "discounted_cash": 5569.38, "setting": 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"additional_generic_notes": "" } ] }, { "description": "ARIPIPRAZOLE LAUROXIL ER 441 MG/1.6ML IM PRSY", "drug_information": { "unit": "1.600000", "type": "UN" }, "code_information": [ { "code": "65757040103", "type": "NDC" } ], "standard_charges": [ { "minimum": 1182.71, "maximum": 3945.18, "gross_charge": 4197.0, "discounted_cash": 2308.35, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2434.26, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2291.56, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3357.6, 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1810.28, "maximum": 6038.55, "gross_charge": 6423.99, "discounted_cash": 3533.19, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3725.91, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3507.5, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5139.19, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5441.12, "standard_charge_percentage": 85.0, "methodology": "percent of total billed 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"methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5653.11, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1810.28, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5460.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4817.99, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2263.17, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4368.31, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6038.55, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5029.98, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3507.5, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { 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"methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ARIPIPRAZOLE LAUROXIL ER 882 MG/3.2ML IM PRSY", "drug_information": { "unit": "3.200000", "type": "UN" }, "code_information": [ { "code": "65757040303", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.76, "maximum": 7890.33, "gross_charge": 8393.97, "discounted_cash": 4616.68, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4868.5, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.76, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 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"N/A", "standard_charge_dollar": 5019.59, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7890.33, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7386.69, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2365.42, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7134.87, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6295.48, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2957.2, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5707.9, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7890.33, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6572.48, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.38, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6673.21, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6295.48, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7386.69, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4868.5, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.76, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "ARMODAFINIL 150 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "63459021530", "type": "NDC" } ], "standard_charges": [ { "minimum": 23.26, "maximum": 77.59, "gross_charge": 82.54, "discounted_cash": 45.4, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.87, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.07, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 66.03, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 69.91, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.02, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.62, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.44, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.36, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 77.59, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 72.64, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.26, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 70.16, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.91, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.08, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 56.13, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 77.59, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 64.63, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.07, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.62, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.91, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 72.64, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.87, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.07, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ARMODAFINIL 250 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "63459022530", "type": "NDC" } ], "standard_charges": [ { "minimum": 23.26, "maximum": 77.59, "gross_charge": 82.54, "discounted_cash": 45.4, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.87, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.07, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 66.03, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 69.91, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.02, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.62, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.44, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.36, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 77.59, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 72.64, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.26, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 70.16, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.91, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.08, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 56.13, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 77.59, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 64.63, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.07, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.62, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.91, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 72.64, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.87, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.07, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ARMODAFINIL 50 MG PO TABS", "drug_information": { "unit": "3.000000", "type": "UN" }, "code_information": [ { "code": "R6345920530", "type": "NDC" } ], "standard_charges": [ { "minimum": 13.27, "maximum": 44.26, "gross_charge": 47.09, "discounted_cash": 25.9, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.31, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.71, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.67, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.89, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.7, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.21, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.16, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 44.26, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.44, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.03, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.32, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.59, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.02, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 44.26, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.87, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.71, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.44, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.32, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.44, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.31, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.71, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ARSENIC TRIOXIDE 10 MG/10ML IV SOLN", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "68382099710", "type": "NDC" } ], "standard_charges": [ { "minimum": 3.93, "maximum": 104.54, "gross_charge": 111.21, "discounted_cash": 61.17, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 64.5, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.93, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.97, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 94.19, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.36, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 53.38, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 66.61, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 66.5, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 104.54, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 97.86, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.34, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 94.53, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 83.41, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.18, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.62, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 104.54, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.08, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.31, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.41, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 83.41, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 97.86, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 64.5, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.93, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "ARTEMETHER-LUMEFANTRINE 20-120 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00078056845", "type": "NDC" } ], "standard_charges": [ { "minimum": 3.58, "maximum": 11.96, "gross_charge": 12.72, "discounted_cash": 7.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.38, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.95, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.77, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.7, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.11, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.62, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.61, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.96, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.19, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.58, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.81, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.54, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.48, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.65, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.96, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.96, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.95, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.11, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.54, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.19, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.38, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.95, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Artery-vein autograft", "code_information": [ { "code": "36825", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 3984.54, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2951.51, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 21102.09, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 38290.1, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3984.54, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 38290.1, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Artery-vein nonautograft", "code_information": [ { "code": "36830", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 3984.54, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2951.51, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 19057.06, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 34579.34, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3984.54, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 34579.34, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ARTESUNATE 110 MG IV SOLR", "drug_information": { "unit": "11.000000", "type": "UN" }, "code_information": [ { "code": "73607001111", "type": "NDC" } ], "standard_charges": [ { "minimum": 3813.08, "maximum": 12719.3, "gross_charge": 13531.17, "discounted_cash": 7442.14, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 7848.08, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 7388.02, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10824.94, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11460.9, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3937.57, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6494.96, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 8105.17, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 8091.64, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12719.3, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11907.43, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3813.08, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11501.49, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10148.38, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 4767.03, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 9201.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 12719.3, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 10594.91, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7388.02, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 10757.28, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10148.38, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11907.43, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7848.08, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7388.02, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Arthr si jt opn b1grf instrm", "code_information": [ { "code": "27280", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 27953.84, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 50722.71, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 50722.71, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Arthrd ant ntrbd min dsc crv", "code_information": [ { "code": "22554", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 9484.13, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 7025.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 45790.27, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 83114.12, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 9484.13, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 83114.12, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Arthrd ant ntrbd min dsc lum", "code_information": [ { "code": "22558", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 70474.54, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 127877.38, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 127877.38, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Arthrd ant ntrbdy cervical", "code_information": [ { "code": "22551", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 9484.13, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 7025.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 42276.3, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 77071.07, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 9484.13, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 77071.07, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Arthrd cmbn 1ntrspc lumbar", "code_information": [ { "code": "22633", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 13555.31, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 10040.97, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 68983.51, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 125171.79, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 13555.31, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 125171.79, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Arthrd pst tq 1ntrspc lum", "code_information": [ { "code": "22630", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 13555.31, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 10040.97, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 64874.6, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 117716.05, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 13555.31, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 117716.05, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Arthrd pst tq 1ntrspc lumbar", "code_information": [ { "code": "22612", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 13555.31, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 10040.97, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 61569.33, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 111718.58, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 13555.31, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 111718.58, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Arthrd si jt perq/min nvas", "code_information": [ { "code": "27279", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 13555.31, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 10040.97, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 31250.5, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 56704.56, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 13555.31, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 56704.56, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Arthrt elbw capsl exc rls", "code_information": [ { "code": "24006", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2391.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1771.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 11824.64, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 21603.6, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2391.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 21603.6, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Arthrt elbw jt expl bx rmvl", "code_information": [ { "code": "24101", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2391.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1771.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 9079.28, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 16474.5, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2391.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 16474.5, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ARTIFICIAL TEARS 83-15 % OP OINT", "drug_information": { "unit": "4.000000", "type": "GR" }, "code_information": [ { "code": "63736014308", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ASCORBIC ACID 25000 MG/50ML IV SOLN", "drug_information": { "unit": "0.500000", "type": "UN" }, "code_information": [ { "code": "67157010150", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 1158.0, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.72, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ASCORBIC ACID 500 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00904052361", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ASENAPINE MALEATE 5 MG SL SUBL", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "42794001610", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.88, "maximum": 6.27, "gross_charge": 6.67, "discounted_cash": 3.67, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.87, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.64, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.34, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.65, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.94, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.0, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.99, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.27, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.87, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.88, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.67, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.35, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.54, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.27, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.22, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.64, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.3, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.87, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.87, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.64, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ASPARAGINASE ERWINIA CHRY-RYWN 10 MG/0.5ML IM SOLN", "drug_information": { "unit": "0.500000", "type": "UN" }, "code_information": [ { "code": "68727090003", "type": "NDC" } ], "standard_charges": [ { "minimum": 4210.09, "maximum": 14043.6, "gross_charge": 14940.0, "discounted_cash": 8217.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 8665.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 8157.24, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11952.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12654.18, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4347.54, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7171.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 8949.06, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 8934.12, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14043.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13147.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 4210.09, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12699.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11205.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 5263.36, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 10159.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 14043.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 11698.02, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8157.24, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 11877.3, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11205.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13147.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8665.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8157.24, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Aspir/inj thyroid cyst", "code_information": [ { "code": "60300", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 518.62, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 384.16, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 5840.51, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 10597.7, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 518.62, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 10597.7, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Aspirate pleura w/ imaging", "code_information": [ { "code": "32555", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 455.72, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 337.57, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 3467.04, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 6291.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 455.72, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 6291.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Aspirate pleura w/o imaging", "code_information": [ { "code": "32554", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 455.72, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 337.57, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 6409.08, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 11629.4, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 455.72, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 11629.4, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Aspirate/inj ganglion cyst", "code_information": [ { "code": "20612", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 217.58, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 161.17, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 8533.67, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 15488.09, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 217.58, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 15488.09, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Aspiration orbital contents", "code_information": [ { "code": "67415", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1719.62, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1273.8, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 13390.86, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 24297.94, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1719.62, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 24297.94, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ASPIRIN 0.1 MG/ML FOR DESENSITIZATION", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "C6373943401", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ASPIRIN 1 MG/ML FOR DESENSITIZATION", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "C6373943401_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ASPIRIN 10 MG/ML ORAL SUSPENSION", "drug_information": { "unit": "8.100000", "type": "UN" }, "code_information": [ { "code": "08252000057", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ASPIRIN 300 MG RE SUPP", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00574703412", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ASPIRIN 325 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "66553000101", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ASPIRIN 325 MG PO TBEC", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "1013512601", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ASPIRIN 8.1 MG/ML ORAL SUSPENSION", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "08252000056", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.83, "maximum": 106.17, "gross_charge": 112.95, "discounted_cash": 62.12, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.51, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.67, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 90.36, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 95.67, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.87, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.22, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 67.66, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 67.54, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 106.17, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 99.4, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.83, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.01, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 84.71, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.79, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 76.81, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 106.17, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.44, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.67, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 89.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 84.71, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 99.4, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.51, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.67, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ASPIRIN 80 MG SUPPOSITORY", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "P0904404073", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 1158.0, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.47, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ASPIRIN 80 MG SUPPOSITORY (NICU)", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "P0904404073_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 1158.0, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.47, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ASPIRIN 81 MG PO CHEW", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "66553000201", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ASPIRIN 81 MG PO CHEW (NICU)", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "66553000201_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ASPIRIN 81 MG PO TBEC", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "R7139986271", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ASPIRIN-DIPYRIDAMOLE ER 25-200 MG PO CP12", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "65162059606", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Assess cyst contrast inject", "code_information": [ { "code": "49424", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 992.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 1800.01, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 1800.01, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ATAZANAVIR SULFATE 200 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "65862071260", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.9, "maximum": 6.33, "gross_charge": 6.73, "discounted_cash": 3.7, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.9, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.67, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.38, "standard_charge_percentage": 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"standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.33, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.92, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.9, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.72, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.05, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.37, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.58, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.33, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.27, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.67, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.35, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.05, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.92, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.9, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.67, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ATAZANAVIR SULFATE 300 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00093552856", "type": "NDC" } ], "standard_charges": [ { "minimum": 6.72, "maximum": 22.43, "gross_charge": 23.86, "discounted_cash": 13.12, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.84, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.03, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.09, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.21, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.94, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.45, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.29, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.27, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.43, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.72, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.28, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.9, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.22, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.43, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.68, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.03, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.97, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.9, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.84, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.03, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ATAZANAVIR-COBICISTAT 300-150 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00003364111", "type": "NDC" } ], "standard_charges": [ { "minimum": 34.15, "maximum": 113.9, "gross_charge": 121.17, "discounted_cash": 66.64, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 70.28, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 66.16, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.94, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 102.63, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.26, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 58.16, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 72.58, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 72.46, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 113.9, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 106.63, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.15, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 102.99, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 90.88, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.69, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.4, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 113.9, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 94.88, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 66.16, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.33, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 90.88, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 106.63, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 70.28, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 66.16, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ATENOLOL 10 MG/ML SUSPENSION", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "P5107975920", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ATENOLOL 100 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "51079068520", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ATENOLOL 12.5 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "R0378021801", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ATENOLOL 25 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "51079075920", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", 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"standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total 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"percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": 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"All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ATEZOLIZUMAB 1200 MG/20ML IV SOLN", "drug_information": { "unit": "20.000000", "type": "UN" }, "code_information": [ { "code": "50242091701", "type": "NDC" } ], "standard_charges": [ { "minimum": 47.09, "maximum": 30805.93, "gross_charge": 32772.27, "discounted_cash": 18024.75, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 19007.92, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.09, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 26217.82, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 27758.11, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9536.73, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15730.69, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 19630.59, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 11394.0, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30805.93, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 28839.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 9235.23, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 27856.43, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 24579.2, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11545.67, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 22285.14, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 30805.93, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 25660.69, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.57, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 15189.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 24579.2, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 28839.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 19007.92, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.09, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "ATOMOXETINE HCL 10 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "55111051930", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ATOMOXETINE HCL 18 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "64980037403", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ATOMOXETINE HCL 25 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687056721", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.19, "maximum": 3.97, "gross_charge": 4.22, "discounted_cash": 2.32, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.45, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.3, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.38, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.57, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.23, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.03, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.53, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.52, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.97, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.71, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.19, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.59, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.17, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.49, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.87, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.97, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.3, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.3, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.35, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.17, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.71, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.45, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.3, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ATOMOXETINE HCL 40 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687032625", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.83, "maximum": 6.09, "gross_charge": 6.48, "discounted_cash": 3.56, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.54, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.49, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.89, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.11, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.88, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.88, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.09, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.7, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.83, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.51, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.86, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.28, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.41, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.09, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.07, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.54, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.15, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.86, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.7, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.54, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ATOMOXETINE HCL 60 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00093354656", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.57, "maximum": 8.56, "gross_charge": 9.11, "discounted_cash": 5.01, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.28, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.97, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.29, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.72, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.65, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.46, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.45, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.56, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.02, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.57, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.74, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.83, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.21, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.19, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.56, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.97, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.24, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.83, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.02, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.28, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.97, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ATOMOXETINE HCL 80 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "55111056330", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ATORVASTATIN CALCIUM 10 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68084009701", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ATORVASTATIN CALCIUM 20 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00904629161", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ATORVASTATIN CALCIUM 40 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68084009901", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ATORVASTATIN CALCIUM 80 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68084059025", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ATOVAQUONE 750 MG/5ML PO SUSP", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "60687053478", "type": "NDC" } ], "standard_charges": [ { "minimum": 6.86, "maximum": 22.87, "gross_charge": 24.33, "discounted_cash": 13.38, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.11, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.28, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.46, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.61, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.08, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.68, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.57, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.55, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.87, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.41, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.86, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.68, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.25, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.57, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.54, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.87, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.05, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.28, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.34, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.25, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.41, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.11, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.28, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ATOVAQUONE-PROGUANIL HCL 250-100 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68001024515", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.92, "maximum": 6.42, "gross_charge": 6.83, "discounted_cash": 3.76, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.96, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.73, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.46, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.79, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.99, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.28, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.09, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.08, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.42, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.01, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.81, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.12, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.42, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.35, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.73, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.43, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.12, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.01, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.96, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.73, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ATOVAQUONE-PROGUANIL HCL 62.5-25 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00378416001", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.35, "maximum": 4.5, "gross_charge": 4.79, "discounted_cash": 2.63, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.78, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.62, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.83, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.06, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.39, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.3, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.87, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.86, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.5, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.22, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.35, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.07, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.59, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.69, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.26, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.5, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.75, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.62, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.81, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.59, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.22, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.78, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.62, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ATRACURIUM BESYLATE 50 MG/5ML IV SOLN", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "55150021605", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 1158.0, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.72, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ATRAPRO DERMAL SPRAY EX LIQD", "drug_information": { "unit": "236.000000", "type": "UN" }, "code_information": [ { "code": "23710006508", "type": "NDC" } ], "standard_charges": [ { "minimum": 176.01, "maximum": 587.11, "gross_charge": 624.58, "discounted_cash": 343.52, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 362.26, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 341.02, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 499.66, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 529.02, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 181.75, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 299.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 374.12, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 373.5, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 587.11, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 549.63, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 176.01, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 530.89, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 468.44, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 220.04, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 424.71, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 587.11, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 489.05, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 341.02, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 496.54, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 468.44, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 549.63, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 362.26, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 341.02, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ATRAPRO HYDROGEL EX GEL", "drug_information": { "unit": "113.000000", "type": "GR" }, "code_information": [ { "code": "23710006004", "type": "NDC" } ], "standard_charges": [ { "minimum": 155.01, "maximum": 517.08, "gross_charge": 550.08, "discounted_cash": 302.54, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 319.05, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 300.34, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 440.06, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 465.92, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 160.07, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 264.04, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 329.5, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 328.95, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 517.08, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 484.07, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 155.01, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 467.57, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 412.56, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 193.79, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 374.05, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 517.08, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 430.71, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 300.34, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 437.31, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 412.56, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 484.07, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 319.05, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 300.34, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ATROPINE 0.4 MG/ML 20ML (BULK CHARGE)", "drug_information": { "unit": "20.000000", "type": "UN" }, "code_information": [ { "code": "16729051243", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, 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billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": 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"methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 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"standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ATROPINE SULFATE 0.4 MG/ML IV SOLN", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00517100425", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", 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"payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ATROPINE SULFATE 1 % OP SOLN", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "60219174903", "type": "NDC" } ], "standard_charges": [ { "minimum": 24.02, "maximum": 80.12, "gross_charge": 85.23, "discounted_cash": 46.88, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.43, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.54, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 68.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 72.19, "standard_charge_percentage": 85.0, "methodology": 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94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.02, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 72.45, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.92, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.03, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 57.96, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 80.12, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 66.74, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.54, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 67.76, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.92, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.43, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.54, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ATROPINE SULFATE 1 MG/10ML IJ SOSY", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "76329334001_3", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { 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"standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ATROPINE SULFATE 1 MG/ML IV SOLN", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00517100125", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ATROPINE SULFATE 1% OP SOLN 2ML (BULK CHARGE)", "drug_information": { "unit": "2.000000", "type": "UN" }, "code_information": [ { "code": "60219174802", "type": "NDC" } ], "standard_charges": [ { "minimum": 19.68, "maximum": 65.66, "gross_charge": 69.85, "discounted_cash": 38.42, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.51, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.14, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.88, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.16, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.33, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.53, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.84, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.77, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.66, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.47, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.68, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.37, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.39, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.61, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.5, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.66, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.69, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.14, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.53, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.39, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.47, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.51, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.14, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ATROPINE SULFATE 1.2 MG/3ML IV SOSY", "drug_information": { "unit": "3.000000", "type": "UN" }, "code_information": [ { "code": "69374093503", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ATROPINE SULFATE 8 MG/20ML IJ SOLN", "drug_information": { "unit": "20.000000", "type": "UN" }, "code_information": [ { "code": "16729051243_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Attach bladder/urethra", "code_information": [ { "code": "51841", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 42584.57, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 80313.78, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 80313.78, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Augmentation cheek bone", "code_information": [ { "code": "21270", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4360.43, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3229.95, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 66768.75, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 121153.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4360.43, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 121153.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Augmentation lower jaw bone", "code_information": [ { "code": "21125", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4360.43, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3229.95, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 27279.04, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 49506.03, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4360.43, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 49506.03, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Augmentation of facial bones", "code_information": [ { "code": "21208", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4360.43, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3229.95, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 83655.97, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 151795.11, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4360.43, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 151795.11, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Autgrft implnt knee w/scope", "code_information": [ { "code": "29866", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 5265.64, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3900.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 14781.44, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 26821.17, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5265.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 26821.17, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Autochondrocyte implant knee", "code_information": [ { "code": "27412", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 5265.64, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3900.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 17055.47, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 30947.45, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5265.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 30947.45, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Av fistula revision", "code_information": [ { "code": "36833", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 3984.54, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2951.51, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 18231.25, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 33080.93, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3984.54, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 33080.93, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Av fistula revision open", "code_information": [ { "code": "36832", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 3984.54, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2951.51, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 16294.66, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 29566.94, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3984.54, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 29566.94, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Av fuse uppr arm basilic", "code_information": [ { "code": "36819", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 3984.54, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2951.51, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": 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"fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 22458.74, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Av fusion direct any site", "code_information": [ { "code": "36821", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2320.02, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1718.54, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 13578.57, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 24638.54, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2320.02, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 24638.54, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AVACINCAPTAD PEGOL 2 MG/0.1ML IZ SOLN", "drug_information": { "unit": "0.100000", "type": "UN" }, "code_information": [ { "code": "82829000201", "type": "NDC" } ], "standard_charges": [ { "minimum": 1775.34, "maximum": 5922.0, "gross_charge": 6300.0, 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"Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5544.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1775.34, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5355.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4725.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2219.49, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4284.0, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5922.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4932.9, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3439.8, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5008.5, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4725.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5544.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3654.0, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3439.8, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AVACOPAN 10 MG PO CAPS", "drug_information": { "unit": "3.000000", "type": "UN" }, "code_information": [ { "code": "73556016801", "type": "NDC" } ], "standard_charges": [ { "minimum": 233.19, "maximum": 777.84, "gross_charge": 827.49, "discounted_cash": 455.12, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 479.94, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 451.81, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 661.99, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 700.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 240.8, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 397.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 495.67, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 494.84, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 777.84, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 728.19, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 233.19, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 703.37, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 620.62, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 291.52, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 562.69, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 777.84, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 647.92, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 451.81, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 657.85, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 620.62, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 728.19, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 479.94, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 451.81, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AVALGLUCOSIDASE ALFA-NGPT 100 MG IV SOLR", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "58468042601", "type": "NDC" } ], "standard_charges": [ { "minimum": 42.45, "maximum": 5230.17, "gross_charge": 5564.01, "discounted_cash": 3060.21, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3227.13, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.45, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4451.21, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4712.72, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1619.13, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2670.72, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3332.84, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 3327.28, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5230.17, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4896.33, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1567.94, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4729.41, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4173.01, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1960.2, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3783.53, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5230.17, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4356.62, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 57.31, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4423.39, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4173.01, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4896.33, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3227.13, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.45, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "AVEENO MOISTURIZING EX BAR", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "08137003623", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.65, "maximum": 5.5, "gross_charge": 5.85, "discounted_cash": 3.22, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.19, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.68, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.95, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.7, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.81, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.5, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.5, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.5, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.15, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.65, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.97, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.39, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.06, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.98, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.5, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.58, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.19, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.65, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.39, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.15, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.19, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AVEENO SOOTHING BATH TREATMENT EX PACK", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "08137003640", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AYR SALINE NASAL NA GEL", "drug_information": { "unit": "15.000000", "type": "GR" }, "code_information": [ { "code": "00225052547", "type": "NDC" } ], "standard_charges": [ { "minimum": 3.55, "maximum": 11.84, "gross_charge": 12.6, "discounted_cash": 6.93, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.31, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.88, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.08, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.67, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.67, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.05, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.55, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.53, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.84, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.09, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.55, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.71, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.45, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.44, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.57, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.84, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.87, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.88, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.02, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.45, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.09, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.31, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.88, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AZACITIDINE 100 MG IJ SUSR", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "71288011530", "type": "NDC" } ], "standard_charges": [ { "minimum": 18.57, "maximum": 61.95, "gross_charge": 65.9, "discounted_cash": 36.25, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.98, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.72, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.82, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.18, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.63, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.47, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.41, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.95, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 57.99, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.57, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 56.02, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.43, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.22, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 44.81, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.95, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 51.6, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.98, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.39, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.43, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 57.99, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.98, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AZACITIDINE CHEMO SC SYRINGE", "drug_information": { "unit": "4.000000", "type": "UN" }, "code_information": [ { "code": "71288011530_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 18.57, "maximum": 61.95, "gross_charge": 65.9, "discounted_cash": 36.25, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.98, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.72, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.82, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.18, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.63, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.47, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.41, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.95, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 57.99, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.57, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 56.02, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.43, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.22, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": 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"percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.43, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 57.99, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.98, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AZATHIOPRINE 10MG/ML ORAL SUSPENSION", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "08252000159", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AZATHIOPRINE 50 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68084022901", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AZATHIOPRINE SODIUM 100 MG IJ SOLR", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "00143956601", "type": "NDC" } ], "standard_charges": [ { "minimum": 128.68, "maximum": 657.05, "gross_charge": 698.99, "discounted_cash": 384.44, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 405.41, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 128.68, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 559.19, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 592.04, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 203.41, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 335.52, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 418.7, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 418.0, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 657.05, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 615.11, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 196.98, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 594.14, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 524.24, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 246.25, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 475.31, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 657.05, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 547.31, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 173.71, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 555.7, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 524.24, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 615.11, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 405.41, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 128.68, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "AZELAIC ACID 15 % EX GEL", "drug_information": { "unit": "50.000000", "type": "GR" }, "code_information": [ { "code": "68462062652", "type": "NDC" } ], "standard_charges": [ { "minimum": 95.71, "maximum": 319.27, "gross_charge": 339.65, "discounted_cash": 186.81, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 197.0, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 185.45, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 271.72, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 287.68, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 98.84, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 163.03, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 203.45, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 203.11, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 319.27, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 298.89, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 95.71, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 288.7, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 254.74, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 119.66, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 230.96, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 319.27, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 265.95, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 185.45, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 270.02, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 254.74, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 298.89, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 197.0, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 185.45, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AZELASTINE HCL 0.05 % OP SOLN", "drug_information": { "unit": "6.000000", "type": "UN" }, "code_information": [ { "code": "70069009101", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AZELASTINE HCL 0.1 % NA SOLN", "drug_information": { "unit": "30.000000", "type": "UN" }, "code_information": [ { "code": "60505083305", "type": "NDC" } ], "standard_charges": [ { "minimum": 7.07, "maximum": 23.59, "gross_charge": 25.1, "discounted_cash": 13.81, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.56, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.7, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.08, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.26, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.3, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.05, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.03, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.01, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.59, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.09, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.07, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.34, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.83, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.84, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.07, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.59, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.65, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.7, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.95, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.83, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.09, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.56, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.7, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AZELASTINE-FLUTICASONE 137-50 MCG/ACT NA SUSP", "drug_information": { "unit": "23.000000", "type": "GR" }, "code_information": [ { "code": "00037024523", "type": "NDC" } ], "standard_charges": [ { "minimum": 133.75, "maximum": 446.15, "gross_charge": 474.63, "discounted_cash": 261.05, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 275.29, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 259.15, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 379.7, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 402.01, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 138.12, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 227.82, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 284.3, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 283.83, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 446.15, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 417.67, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 133.75, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 403.44, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 355.97, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 167.21, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 322.75, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 446.15, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 371.64, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 259.15, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 377.33, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 355.97, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 417.67, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 275.29, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 259.15, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AZITHROMYCIN 1 % OP SOLN", "drug_information": { "unit": "2.500000", "type": "UN" }, "code_information": [ { "code": "17478030703", "type": "NDC" } ], "standard_charges": [ { "minimum": 198.6, "maximum": 662.47, "gross_charge": 704.76, "discounted_cash": 387.62, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 408.76, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 384.8, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 563.81, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 596.93, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 205.09, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 338.28, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 422.15, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 421.45, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 662.47, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 620.19, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 198.6, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 599.05, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 528.57, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 248.29, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 479.24, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 662.47, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 551.83, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 384.8, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 560.28, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 528.57, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 620.19, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 408.76, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 384.8, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AZITHROMYCIN 100 MG/5ML PO SUSR", "drug_information": { "unit": "15.000000", "type": "UN" }, "code_information": [ { "code": "00093202723", "type": "NDC" } ], "standard_charges": [ { "minimum": 6.58, "maximum": 21.95, "gross_charge": 23.35, "discounted_cash": 12.84, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.54, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.75, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.68, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.78, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.79, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.21, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.99, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.95, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.55, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.58, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.85, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.51, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.23, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.88, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.95, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.28, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.75, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.56, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.51, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.55, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.54, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.75, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AZITHROMYCIN 200 MG/5ML PO SUSR", "drug_information": { "unit": "22.500000", "type": "UN" }, "code_information": [ { "code": "00093202694", "type": "NDC" } ], "standard_charges": [ { "minimum": 7.17, "maximum": 23.92, "gross_charge": 25.45, "discounted_cash": 14.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.76, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.9, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.36, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.56, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.41, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.22, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.24, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.22, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.4, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.17, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.63, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.09, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.97, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.31, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.93, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.9, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.23, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.09, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.4, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.76, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.9, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AZITHROMYCIN 250 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687074201", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AZTREONAM 1 G IJ SOLR", "drug_information": { "unit": "4.000000", "type": "UN" }, "code_information": [ { "code": "63323040120", "type": "NDC" } ], "standard_charges": [ { "minimum": 14.08, "maximum": 46.97, "gross_charge": 49.97, "discounted_cash": 27.48, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.98, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.28, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.98, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.32, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.54, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.99, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.93, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.88, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.97, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.97, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.08, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.47, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.48, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.6, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.98, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.97, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.28, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.73, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.48, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.97, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.98, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.28, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AZTREONAM 1 G IV SOLR", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "63323040120_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 14.08, "maximum": 46.97, "gross_charge": 49.97, "discounted_cash": 27.48, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.98, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.28, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.98, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.32, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.54, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.99, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.93, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.88, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.97, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.97, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.08, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.47, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.48, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.6, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.98, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.97, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.28, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.73, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.48, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.97, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.98, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.28, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AZTREONAM 2 G IJ SOLR", "drug_information": { "unit": "8.000000", "type": "UN" }, "code_information": [ { "code": "63323040220", "type": "NDC" } ], "standard_charges": [ { "minimum": 28.76, "maximum": 95.93, "gross_charge": 102.05, "discounted_cash": 56.13, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.19, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.72, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 81.64, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.44, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.7, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 48.98, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.13, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.03, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 95.93, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 89.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.76, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.74, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 76.54, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.95, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 69.39, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 95.93, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 79.91, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.72, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 81.13, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 76.54, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 89.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.19, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.72, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "AZTREONAM 2 G IV SOLR", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "63323040220_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 28.76, "maximum": 95.93, "gross_charge": 102.05, "discounted_cash": 56.13, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.19, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.72, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 81.64, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.44, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.7, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 48.98, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.13, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.03, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 95.93, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 89.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.76, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.74, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 76.54, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.95, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 69.39, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 95.93, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 79.91, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.72, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 81.13, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 76.54, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 89.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.19, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.72, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "B COMPLEX PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "1184506011", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BACITRA-NEOMYCIN-POLYMYXIN-HC 1 % OP OINT", "drug_information": { "unit": "4.000000", "type": "GR" }, "code_information": [ { "code": "24208078555", "type": "NDC" } ], "standard_charges": [ { "minimum": 48.78, "maximum": 162.71, "gross_charge": 173.1, "discounted_cash": 95.21, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 100.4, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 94.51, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 138.48, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 146.62, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.37, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 83.09, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.69, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.51, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 162.71, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 152.33, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 48.78, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 147.14, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 129.83, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.98, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 117.71, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 162.71, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 135.54, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 94.51, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 137.61, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 129.83, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 152.33, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 100.4, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 94.51, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BACITRACIN 500 UNIT/GM OP OINT", "drug_information": { "unit": "4.000000", "type": "GR" }, "code_information": [ { "code": "00574402235", "type": "NDC" } ], "standard_charges": [ { "minimum": 165.97, "maximum": 553.64, "gross_charge": 588.98, "discounted_cash": 323.94, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 341.61, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 321.58, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 471.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 498.87, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 171.39, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 282.71, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 352.8, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 352.21, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 553.64, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 518.3, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 165.97, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 500.63, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 441.74, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 207.5, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 400.51, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 553.64, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 461.17, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 321.58, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 468.24, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 441.74, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 518.3, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 341.61, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 321.58, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BACITRACIN ZINC 500 UNIT/GM EX OINT", "drug_information": { "unit": "29.000000", "type": "GR" }, "code_information": [ { "code": "51672207502", "type": "NDC" } ], "standard_charges": [ { "minimum": 5.95, "maximum": 19.83, "gross_charge": 21.1, "discounted_cash": 11.61, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.24, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.52, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.88, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.87, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.14, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.13, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.64, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.62, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.83, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.57, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.95, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.94, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.83, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.43, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.35, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.83, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.52, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.52, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.77, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.83, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.57, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.24, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.52, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BACITRACIN ZINC 500 UNIT/GM EX OINT 15GM (BULK CHARGE)", "drug_information": { "unit": "15.000000", "type": "GR" }, "code_information": [ { "code": "51672207501", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.03, "maximum": 6.77, "gross_charge": 7.2, "discounted_cash": 3.96, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.18, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.93, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.76, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.1, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.1, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.46, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.31, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.31, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.77, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.34, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.03, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.12, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.4, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.54, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.9, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.77, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.64, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.93, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.72, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.4, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.34, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.18, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.93, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BACITRACIN-NEOMYCIN-POLYMIXIN EX OINT 0.9GM (BULK CHARGE)", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00904880567", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BACITRACIN-POLYMYXIN B 500-10000 UNIT/GM OP OINT", "drug_information": { "unit": "4.000000", "type": "GR" }, "code_information": [ { "code": "24208055555", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BACLOFEN 0.05 MG/ML IT SOLN", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "70257056255", "type": "NDC" } ], "standard_charges": [ { "minimum": 24.66, "maximum": 82.25, "gross_charge": 87.5, "discounted_cash": 48.13, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.75, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.78, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 70.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.11, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.46, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.0, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.41, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.33, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.25, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 77.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.66, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.38, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.63, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.83, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.5, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.25, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 68.51, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.78, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 69.56, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.63, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 77.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.75, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.78, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BACLOFEN 10 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "50268010615", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BACLOFEN 10 MG/20ML IT SOLN", "drug_information": { "unit": "20.000000", "type": "UN" }, "code_information": [ { "code": "67457056220", "type": "NDC" } ], "standard_charges": [ { "minimum": 95.32, "maximum": 552.92, "gross_charge": 588.21, "discounted_cash": 323.52, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 341.16, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 95.32, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 470.57, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 498.21, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 171.17, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 282.34, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 352.34, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 351.75, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 552.92, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 517.62, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 165.76, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 499.98, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 441.16, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 207.23, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 399.98, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 552.92, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 460.57, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 128.68, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 467.63, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 441.16, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 517.62, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 341.16, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 95.32, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "BACLOFEN 10 MG/5ML IT SOLN", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "70257056102", "type": "NDC" } ], "standard_charges": [ { "minimum": 95.32, "maximum": 575.75, "gross_charge": 612.5, "discounted_cash": 336.88, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 355.25, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 95.32, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 490.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 518.79, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 178.24, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 294.0, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 366.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 366.28, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 575.75, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 539.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 172.6, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 520.63, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 459.38, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 215.78, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 416.5, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 575.75, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 479.59, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 128.68, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 486.94, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 459.38, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 539.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 355.25, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 95.32, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "BACLOFEN 10000 MCG/20ML IT SOSY", "drug_information": { "unit": "20.000000", "type": "UN" }, "code_information": [ { "code": "66794015501", "type": "NDC" } ], "standard_charges": [ { "minimum": 95.32, "maximum": 587.27, "gross_charge": 624.75, "discounted_cash": 343.61, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 362.36, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 95.32, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 499.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 529.16, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 181.8, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 299.88, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 374.23, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 373.6, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 587.27, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 549.78, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 176.05, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 531.04, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 468.56, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 220.1, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 424.83, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 587.27, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 489.18, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 128.68, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 496.68, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 468.56, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 549.78, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 362.36, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 95.32, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "BACLOFEN 20 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687082601", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BACLOFEN 20000 MCG/20ML IT SOSY", "drug_information": { "unit": "20.000000", "type": "UN" }, "code_information": [ { "code": "66794015601", "type": "NDC" } ], "standard_charges": [ { "minimum": 95.32, "maximum": 1323.14, "gross_charge": 1407.6, "discounted_cash": 774.18, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 816.41, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 95.32, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1126.08, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1192.24, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 409.61, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 675.65, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 843.15, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 841.74, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1323.14, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1238.69, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 396.66, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1196.46, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1055.7, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 495.9, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 957.17, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1323.14, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1102.15, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 128.68, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1119.04, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1055.7, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1238.69, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 816.41, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 95.32, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "BACLOFEN 25 MG/5ML PO SUSP", "drug_information": { "unit": "0.500000", "type": "UN" }, "code_information": [ { "code": "52536060011", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.36, "maximum": 4.52, "gross_charge": 4.81, "discounted_cash": 2.65, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.79, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.63, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.85, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.07, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.4, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.31, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.88, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.88, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.23, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.36, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.09, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.61, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.69, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.27, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.77, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.63, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.82, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.61, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.23, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.79, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.63, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BACLOFEN 40 MG/20ML IT SOLN", "drug_information": { "unit": "20.000000", "type": "UN" }, "code_information": [ { "code": "67457056420", "type": "NDC" } ], "standard_charges": [ { "minimum": 95.32, "maximum": 2071.99, "gross_charge": 2204.24, "discounted_cash": 1212.33, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1278.46, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 95.32, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1763.39, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1866.99, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 641.43, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1058.04, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1320.34, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 1318.14, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2071.99, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1939.73, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 621.15, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1873.6, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1653.18, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 776.55, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1498.88, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2071.99, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1725.92, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 128.68, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1752.37, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1653.18, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1939.73, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1278.46, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 95.32, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "BACLOFEN 40000 MCG/20ML IT SOSY", "drug_information": { "unit": "20.000000", "type": "UN" }, "code_information": [ { "code": "66794015701", "type": "NDC" } ], "standard_charges": [ { "minimum": 95.32, "maximum": 2489.04, "gross_charge": 2647.92, "discounted_cash": 1456.36, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1535.79, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 95.32, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2118.34, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2242.79, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 770.54, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1271.0, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1586.1, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 1583.46, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2489.04, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2330.17, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 746.18, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2250.73, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1985.94, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 932.86, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1800.59, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2489.04, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2073.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 128.68, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2105.1, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1985.94, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2330.17, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1535.79, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 95.32, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "BACLOFEN 5 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "50268010515", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BACLOFEN 5 MG/ML PO SUSP (PTL)", "drug_information": { "unit": "0.500000", "type": "UN" }, "code_information": [ { "code": "08252000076", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BACLOFEN 50 MCG/ML IT SOSY", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "66794015101", "type": "NDC" } ], "standard_charges": [ { "minimum": 62.09, "maximum": 207.1, "gross_charge": 220.32, "discounted_cash": 121.18, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 127.79, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 120.29, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 176.26, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 186.61, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 64.11, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 105.75, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 131.97, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 131.75, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 207.1, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 193.88, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 62.09, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 187.27, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 165.24, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 77.62, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 149.82, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 207.1, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 172.51, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 120.29, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 175.15, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 165.24, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 193.88, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 127.79, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 120.29, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BACTERIOSTATIC WATER(BENZ ALC) IJ SOLN", "drug_information": { "unit": "30.000000", "type": "UN" }, "code_information": [ { "code": "00409397703", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 1158.0, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.72, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BALSALAZIDE DISODIUM 750 MG PO CAPS", "drug_information": { "unit": "3.000000", "type": "UN" }, "code_information": [ { "code": "00054007928", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.44, "maximum": 4.81, "gross_charge": 5.12, "discounted_cash": 2.82, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.97, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.8, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.1, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.34, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.49, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.46, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.07, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.06, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.81, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.51, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.44, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.35, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.84, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.8, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.48, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.81, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.01, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.8, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.07, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.84, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.51, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.97, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.8, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BARICITINIB 1 MG PO TABS (COVID-19 USE ONLY)", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00002473230", "type": "NDC" } ], "standard_charges": [ { "minimum": 68.88, "maximum": 229.77, "gross_charge": 244.44, "discounted_cash": 134.44, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 141.78, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 133.46, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 195.55, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 207.04, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 71.13, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 117.33, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 146.42, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 146.18, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 229.77, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 215.11, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 68.88, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 207.77, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 183.33, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.12, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 166.22, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 229.77, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 191.4, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 133.46, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 194.33, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 183.33, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 215.11, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 141.78, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 133.46, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BARICITINIB 2 MG PO TABS (COVID-19 USE ONLY)", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00002418230", "type": "NDC" } ], "standard_charges": [ { "minimum": 68.88, "maximum": 229.77, "gross_charge": 244.44, "discounted_cash": 134.44, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 141.78, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 133.46, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 195.55, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 207.04, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 71.13, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 117.33, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 146.42, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 146.18, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 229.77, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 215.11, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 68.88, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 207.77, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 183.33, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.12, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 166.22, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 229.77, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 191.4, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 133.46, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 194.33, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 183.33, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 215.11, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 141.78, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 133.46, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BASILIXIMAB 10 MG IV SOLR", "drug_information": { "unit": "2.500000", "type": "UN" }, "code_information": [ { "code": "00078039361", "type": "NDC" } ], "standard_charges": [ { "minimum": 2505.47, "maximum": 9315.56, "gross_charge": 9910.17, "discounted_cash": 5450.59, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5747.9, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2505.47, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7928.14, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8393.91, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2883.86, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4756.88, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5936.19, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 5926.28, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9315.56, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8720.95, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2792.69, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8423.64, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7432.63, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3491.35, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6738.92, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 9315.56, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7759.66, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3382.38, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7878.59, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7432.63, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8720.95, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5747.9, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2505.47, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "BASILIXIMAB 20 MG IV SOLR", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "00078033184", "type": "NDC" } ], "standard_charges": [ { "minimum": 2505.47, "maximum": 12226.62, "gross_charge": 13007.04, "discounted_cash": 7153.87, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 7544.08, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2505.47, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10405.63, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11016.96, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3785.05, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6243.38, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7791.22, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 7778.21, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12226.62, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11446.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3665.38, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11055.98, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9755.28, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 4582.38, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 8844.79, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 12226.62, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 10184.51, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3382.38, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 10340.6, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9755.28, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11446.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7544.08, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2505.47, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "BCG LIVE 50 MG IS SUSR", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00052060202", "type": "NDC" } ], "standard_charges": [ { "minimum": 151.71, "maximum": 506.07, "gross_charge": 538.37, "discounted_cash": 296.1, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 312.25, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 293.95, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 430.7, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { 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total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 506.07, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 473.77, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 151.71, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 457.61, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 403.78, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 189.67, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 366.09, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 506.07, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 421.54, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { 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"percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 293.95, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BECAPLERMIN 0.01 % EX GEL", "drug_information": { "unit": "15.000000", "type": "GR" }, "code_information": [ { "code": "50484081015", "type": "NDC" } ], "standard_charges": [ { "minimum": 1041.1, "maximum": 3472.8, "gross_charge": 3694.47, "discounted_cash": 2031.96, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2142.79, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2017.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2955.58, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3129.22, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1075.09, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1773.35, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2212.99, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2209.29, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3472.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3251.13, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1041.1, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3140.3, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2770.85, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1301.56, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2512.24, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3472.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2892.77, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2017.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2937.1, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2770.85, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3251.13, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2142.79, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2017.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BECLOMETHASONE DIPROP HFA 40 MCG/ACT IN AERB", "drug_information": { "unit": "11.000000", "type": "GR" }, "code_information": [ { "code": "59310030240", "type": "NDC" } ], "standard_charges": [ { "minimum": 272.66, "maximum": 909.5, "gross_charge": 967.55, "discounted_cash": 532.15, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 561.18, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 528.28, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 774.04, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 819.51, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 281.56, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 464.42, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 579.56, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 578.59, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 909.5, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 851.44, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 272.66, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 822.42, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 725.66, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 340.87, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 657.93, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 909.5, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 757.59, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 528.28, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 769.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 725.66, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 851.44, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 561.18, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 528.28, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BECLOMETHASONE DIPROP HFA 80 MCG/ACT IN AERB", "drug_information": { "unit": "11.000000", "type": "GR" }, "code_information": [ { "code": "59310030480", "type": "NDC" } ], "standard_charges": [ { "minimum": 365.07, "maximum": 1217.77, "gross_charge": 1295.5, "discounted_cash": 712.53, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 751.39, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 707.34, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1036.4, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1097.29, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 376.99, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 621.84, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 776.0, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 774.71, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1217.77, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1140.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 365.07, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1101.18, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 971.63, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 456.4, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 880.94, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1217.77, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1014.38, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 707.34, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1029.92, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 971.63, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1140.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 751.39, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 707.34, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BECLOMETHASONE DIPROPIONATE 0.5 MG/ML SUSPENSION (PTL)", "drug_information": { "unit": "4.000000", "type": "UN" }, "code_information": [ { "code": "00000000024", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BELATACEPT 250 MG IV SOLR", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "00003037113", "type": "NDC" } ], "standard_charges": [ { "minimum": 1093.25, "maximum": 3646.75, "gross_charge": 3879.52, "discounted_cash": 2133.74, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2250.12, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2118.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3103.62, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3285.95, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1128.94, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1862.17, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2323.83, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2319.95, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3646.75, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3413.98, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1093.25, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3297.59, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2909.64, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1366.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2638.07, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3646.75, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3037.66, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2118.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3084.22, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2909.64, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3413.98, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2250.12, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2118.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BELIMUMAB 120 MG IV SOLR", "drug_information": { "unit": "1.500000", "type": "UN" }, "code_information": [ { "code": "49401010101", "type": "NDC" } ], "standard_charges": [ { "minimum": 29.57, "maximum": 2339.85, "gross_charge": 2489.2, "discounted_cash": 1369.06, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1443.74, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.57, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1991.36, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2108.35, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 724.36, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1194.82, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1491.03, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 1488.54, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2339.85, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2190.5, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 701.46, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2115.82, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1866.9, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 876.95, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1692.66, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2339.85, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1949.04, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.91, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1978.91, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1866.9, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2190.5, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1443.74, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.57, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "BELIMUMAB 400 MG IV SOLR", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "49401010201", "type": "NDC" } ], "standard_charges": [ { "minimum": 29.57, "maximum": 5849.3, "gross_charge": 6222.66, "discounted_cash": 3422.46, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3609.14, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.57, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4978.13, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5270.59, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1810.79, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2986.88, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3727.37, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 3721.15, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5849.3, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5475.94, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1753.55, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5289.26, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4667.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2192.24, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4231.41, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5849.3, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4872.34, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.91, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4947.01, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4667.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5475.94, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3609.14, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.57, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "BELINOSTAT 500 MG IV SOLR", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "72893000201", "type": "NDC" } ], "standard_charges": [ { "minimum": 27.35, "maximum": 6925.55, "gross_charge": 7367.61, "discounted_cash": 4052.19, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4273.21, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.35, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5894.09, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6240.37, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2143.97, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3536.45, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All 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billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6262.47, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5525.71, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2595.61, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5009.97, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", 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"additional_payer_notes": "N/A", "standard_charge_dollar": 6483.5, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4273.21, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.35, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "BELLADONNA ALKALOIDS-OPIUM 16.2-30 MG RE SUPP", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00574704512", "type": "NDC" } ], "standard_charges": [ { "minimum": 14.05, "maximum": 46.86, "gross_charge": 49.85, "discounted_cash": 27.42, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.91, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.88, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.22, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.51, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.93, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.86, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.81, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.86, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.87, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.05, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.37, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.39, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.56, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": 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"percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.39, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.87, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.91, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BELLADONNA ALKALOIDS-OPIUM 16.2-60 MG RE SUPP", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00574704012", "type": "NDC" } ], "standard_charges": [ { "minimum": 17.08, "maximum": 56.96, "gross_charge": 60.6, "discounted_cash": 33.33, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.15, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.09, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 48.48, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 51.33, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.63, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.09, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.3, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.24, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 56.96, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 53.33, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.08, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 51.51, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.45, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.35, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.21, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 56.96, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.45, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.09, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 48.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.45, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 53.33, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.15, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.09, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BENAZEPRIL HCL 10 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "50268011015", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BENAZEPRIL HCL 20 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "50268011115", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BENAZEPRIL HCL 40 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "50268011215", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BENAZEPRIL HCL 5 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "50268010915", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BENAZEPRIL-HYDROCHLOROTHIAZIDE 20-12.5 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00185021101", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BENDAMUSTINE HCL 100 MG/4ML IV SOLN", "drug_information": { "unit": "4.000000", "type": "UN" }, "code_information": [ { "code": "63459034804", "type": "NDC" } ], "standard_charges": [ { "minimum": 1785.18, "maximum": 5954.82, "gross_charge": 6334.92, "discounted_cash": 3484.21, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3674.25, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3458.87, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5067.94, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5365.68, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1843.46, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3040.76, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3794.62, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 3788.28, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5954.82, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5574.73, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1785.18, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5384.68, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4751.19, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2231.79, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4307.75, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5954.82, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4960.24, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3458.87, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5036.26, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4751.19, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5574.73, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3674.25, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3458.87, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BENZOCAINE 20 % MT GEL", "drug_information": { "unit": "30.000000", "type": "GR" }, "code_information": [ { "code": "00283087131", "type": "NDC" } ], "standard_charges": [ { "minimum": 4.76, "maximum": 15.87, "gross_charge": 16.88, "discounted_cash": 9.28, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.79, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.5, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.3, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.91, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.1, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.11, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.09, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.87, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.85, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.76, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.35, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.66, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.95, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.48, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.87, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.22, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.42, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.66, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.85, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.79, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BENZOCAINE 20 % MT SOLN", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00283061026", "type": "NDC" } ], "standard_charges": [ { "minimum": 6.46, "maximum": 21.56, "gross_charge": 22.94, "discounted_cash": 12.62, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.31, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.53, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.35, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.43, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.68, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.01, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.74, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.72, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.56, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.19, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.46, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.21, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.08, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.6, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.56, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.96, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.53, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.24, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.21, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.19, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.31, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.53, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BENZOCAINE 20 % RE OINT", "drug_information": { "unit": "28.000000", "type": "GR" }, "code_information": [ { "code": "63736003751", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.48, "maximum": 8.27, "gross_charge": 8.8, "discounted_cash": 4.84, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.1, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.8, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.45, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.56, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.22, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.27, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.26, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.27, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.74, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.48, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.48, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.6, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.1, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.98, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.27, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.89, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.8, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.6, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.74, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.1, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.8, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BENZOCAINE 20% LIDOCAINE 8% TETRACAINE 8% CREAM", "drug_information": { "unit": "30.000000", "type": "GR" }, "code_information": [ { "code": "08252000067", "type": "NDC" } ], "standard_charges": [ { "minimum": 18.47, "maximum": 61.62, "gross_charge": 65.55, "discounted_cash": 36.05, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.02, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.79, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.44, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.52, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.08, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.46, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.26, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.2, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.62, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 57.68, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.47, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.72, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.16, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 44.57, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.62, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 51.33, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.79, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.11, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.16, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 57.68, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.02, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.79, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BENZOCAINE-MENTHOL 20-0.5 % EX AERO", "drug_information": { "unit": "85.000000", "type": "GR" }, "code_information": [ { "code": "16864068003", "type": "NDC" } ], "standard_charges": [ { "minimum": 3.35, "maximum": 11.19, "gross_charge": 11.9, "discounted_cash": 6.55, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.9, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.5, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.52, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.08, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.46, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.71, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.13, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.12, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.19, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.47, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.35, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.12, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.93, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.19, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.09, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.19, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.5, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.46, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.93, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.47, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.9, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.5, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BENZOYL PEROXIDE 10 % EX GEL", "drug_information": { "unit": "60.000000", "type": "GR" }, "code_information": [ { "code": "45802030896", "type": "NDC" } ], "standard_charges": [ { "minimum": 9.0, "maximum": 30.03, "gross_charge": 31.95, "discounted_cash": 17.57, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.53, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.44, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.56, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.06, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.3, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.34, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.14, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.11, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.03, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.12, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.16, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.26, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.73, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.03, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.02, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.44, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.4, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.12, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.53, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.44, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BENZOYL PEROXIDE 10 % EX LIQD", "drug_information": { "unit": "148.000000", "type": "GR" }, "code_information": [ { "code": "71399923605", "type": "NDC" } ], "standard_charges": [ { "minimum": 4.09, "maximum": 13.63, "gross_charge": 14.5, "discounted_cash": 7.98, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.41, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.92, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.6, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.28, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.22, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.96, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.69, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.67, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.63, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.76, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.09, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.33, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.88, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.11, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.86, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.63, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.35, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.92, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.53, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.88, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.76, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.41, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.92, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BENZOYL PEROXIDE 5 % EX GEL", "drug_information": { "unit": "60.000000", "type": "GR" }, "code_information": [ { "code": "71399947806", "type": "NDC" } ], "standard_charges": [ { "minimum": 5.29, "maximum": 17.65, "gross_charge": 18.78, "discounted_cash": 10.33, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.89, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.25, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.02, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.91, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.46, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.01, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.25, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.23, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.65, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.53, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.29, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.96, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.62, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.77, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.65, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.7, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.25, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.93, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.53, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.89, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.25, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BENZOYL PEROXIDE 5 % EX LIQD", "drug_information": { "unit": "148.000000", "type": "GR" }, "code_information": [ { "code": "35573045391", "type": "NDC" } ], "standard_charges": [ { "minimum": 3.55, "maximum": 11.83, "gross_charge": 12.58, "discounted_cash": 6.92, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.3, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.87, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.06, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.66, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.66, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.04, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.54, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.83, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.07, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.55, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.69, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.44, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.43, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.55, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.83, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.85, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.87, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.44, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.07, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.3, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.87, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BENZOYL PEROXIDE 7 % EX LIQD", "drug_information": { "unit": "473.000000", "type": "UN" }, "code_information": [ { "code": "42546014516", "type": "NDC" } ], "standard_charges": [ { "minimum": 68.69, "maximum": 229.13, "gross_charge": 243.75, "discounted_cash": 134.06, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 141.38, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 133.09, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 195.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 206.46, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 70.93, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 117.0, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 146.01, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 145.76, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 229.13, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 214.5, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 68.69, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 207.19, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 182.81, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 85.87, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 165.75, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 229.13, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 190.86, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 133.09, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 193.78, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 182.81, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 214.5, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 141.38, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 133.09, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BENZTROPINE MESYLATE 0.5 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68084038101", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BENZTROPINE MESYLATE 1 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68084038801", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BENZTROPINE MESYLATE 1 MG/ML IJ SOLN", "drug_information": { "unit": "2.000000", "type": "UN" }, "code_information": [ { "code": "00143972905", "type": "NDC" } ], "standard_charges": [ { "minimum": 29.26, "maximum": 97.61, "gross_charge": 103.84, "discounted_cash": 57.11, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.23, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 56.7, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 83.07, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.95, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.22, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.84, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 62.2, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 62.1, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 97.61, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 91.38, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.26, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.26, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 77.88, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.58, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 70.61, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 97.61, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 81.31, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 56.7, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.55, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 77.88, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 91.38, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.23, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 56.7, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BENZTROPINE MESYLATE 2 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68084038901", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BENZYLPENICILLOYL POLYLYSINE 0.25 ML ID SOLN", "drug_information": { "unit": "0.250000", "type": "UN" }, "code_information": [ { "code": "49471000105", "type": "NDC" } ], "standard_charges": [ { "minimum": 150.97, "maximum": 1158.0, "gross_charge": 535.72, "discounted_cash": 294.65, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 310.72, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 292.5, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 465.0, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 155.89, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 257.15, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 320.9, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 320.36, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 503.58, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 471.43, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 150.97, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 455.36, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 401.79, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 188.73, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 364.29, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 503.58, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 419.47, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 292.5, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 425.9, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 401.79, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 471.43, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 310.72, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 292.5, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BERACTANT IN NACL 25-0.9 MG/ML-% INTRATRACHEA SUSP", "drug_information": { "unit": "4.000000", "type": "UN" }, "code_information": [ { "code": "00074104004", "type": "NDC" } ], "standard_charges": [ { "minimum": 205.28, "maximum": 1158.0, "gross_charge": 728.46, "discounted_cash": 400.65, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 422.51, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 397.74, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 632.3, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 211.98, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 349.66, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 436.35, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 435.62, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 684.75, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 641.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 205.28, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 619.19, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 546.35, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 256.64, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 495.35, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 684.75, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 570.38, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 397.74, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 579.13, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 546.35, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 641.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 422.51, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 397.74, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BESIFLOXACIN HCL 0.6 % OP SUSP", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "24208044605", "type": "NDC" } ], "standard_charges": [ { "minimum": 202.46, "maximum": 675.34, "gross_charge": 718.45, "discounted_cash": 395.15, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 416.7, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 392.27, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 574.76, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 608.53, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 209.07, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 344.86, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 430.35, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 429.63, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 675.34, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 632.24, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 202.46, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 610.68, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 538.84, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 253.11, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 488.55, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 675.34, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 562.55, "standard_charge_percentage": 78.0, "methodology": 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"standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 392.27, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BETAMETHASONE DIPROPIONATE 0.05 % EX CREA", "drug_information": { "unit": "15.000000", "type": "GR" }, "code_information": [ { "code": "00168005515", "type": "NDC" } ], "standard_charges": [ { "minimum": 14.93, "maximum": 49.8, "gross_charge": 52.98, "discounted_cash": 29.14, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.73, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.93, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.38, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 44.87, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.42, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.43, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.74, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.68, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.62, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.93, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.03, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.74, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.66, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.03, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.48, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.93, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.12, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.74, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.62, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.73, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.93, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BETAMETHASONE DIPROPIONATE 0.05 % EX LOTN", "drug_information": { "unit": "60.000000", "type": "UN" }, "code_information": [ { "code": "00168005760", "type": "NDC" } ], "standard_charges": [ { "minimum": 16.84, "maximum": 56.17, "gross_charge": 59.75, "discounted_cash": 32.86, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.66, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.62, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.61, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.39, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.68, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.79, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.73, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 56.17, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.58, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.84, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.79, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 44.81, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.05, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.63, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 56.17, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.78, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.62, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.5, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 44.81, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.58, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.66, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.62, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BETAMETHASONE DIPROPIONATE 0.05 % EX OINT", "drug_information": { "unit": "15.000000", "type": "GR" }, "code_information": [ { "code": "00472038115", "type": "NDC" } ], "standard_charges": [ { "minimum": 16.23, "maximum": 54.13, "gross_charge": 57.58, "discounted_cash": 31.67, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.4, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.44, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.06, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 48.77, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.76, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.64, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.49, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.43, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.13, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.67, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.23, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 48.94, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.19, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.29, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.15, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.13, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.09, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.44, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.78, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.19, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.67, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.4, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.44, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BETAMETHASONE DIPROPIONATE AUG 0.05 % EX CREA", "drug_information": { "unit": "15.000000", "type": "GR" }, "code_information": [ { "code": "51672131001", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.54, "maximum": 5.15, "gross_charge": 5.48, "discounted_cash": 3.01, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.99, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.38, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.59, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.63, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.28, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.28, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.15, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.82, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.54, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.66, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.11, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.93, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.73, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.15, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.29, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.99, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.36, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.11, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.82, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.99, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BETAMETHASONE DIPROPIONATE AUG 0.05 % EX GEL", "drug_information": { "unit": "50.000000", "type": "GR" }, "code_information": [ { "code": "51672130903", "type": "NDC" } ], "standard_charges": [ { "minimum": 57.13, "maximum": 190.57, "gross_charge": 202.73, "discounted_cash": 111.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 117.58, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 110.69, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 162.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 171.71, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 58.99, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 97.31, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 121.44, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 121.23, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 190.57, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 178.4, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 57.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 172.32, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 152.05, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 71.42, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 137.86, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 190.57, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 158.74, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 110.69, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 161.17, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 152.05, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 178.4, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 117.58, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 110.69, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BETAMETHASONE DIPROPIONATE AUG 0.05 % EX LOTN", "drug_information": { "unit": "60.000000", "type": "UN" }, "code_information": [ { "code": "00168026760", "type": "NDC" } ], "standard_charges": [ { "minimum": 53.65, "maximum": 178.98, "gross_charge": 190.4, "discounted_cash": 104.72, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 110.43, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.96, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 152.32, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 161.27, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.41, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 91.39, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 114.05, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 113.86, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 178.98, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 167.55, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 53.65, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 161.84, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 142.8, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 67.08, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 129.47, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 178.98, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 149.08, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.96, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 151.37, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 142.8, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 167.55, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 110.43, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.96, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BETAMETHASONE DIPROPIONATE AUG 0.05 % EX OINT", "drug_information": { "unit": "15.000000", "type": "GR" }, "code_information": [ { "code": "66993089715", "type": "NDC" } ], "standard_charges": [ { "minimum": 15.58, "maximum": 51.96, "gross_charge": 55.28, "discounted_cash": 30.4, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.06, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 44.22, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.82, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.09, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.53, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.11, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.06, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 51.96, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 48.65, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.58, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.99, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.46, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.48, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.59, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 51.96, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.28, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.95, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.46, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 48.65, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.06, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BETAMETHASONE SOD PHOS & ACET 6 (3-3) MG/ML IJ SUSP", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "00517072001", "type": "NDC" } ], "standard_charges": [ { "minimum": 23.68, "maximum": 78.99, "gross_charge": 84.03, "discounted_cash": 46.22, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 48.74, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.88, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 67.22, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 71.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.45, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.33, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.33, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.25, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 78.99, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 73.95, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.68, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 71.43, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.02, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.6, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 57.14, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 78.99, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.8, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.88, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 66.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.02, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 73.95, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 48.74, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.88, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BETAMETHASONE VALERATE 0.1 % EX CREA", "drug_information": { "unit": "15.000000", "type": "GR" }, "code_information": [ { "code": "00168004015", "type": "NDC" } ], "standard_charges": [ { "minimum": 6.88, "maximum": 22.96, "gross_charge": 24.43, "discounted_cash": 13.44, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.17, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.34, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.54, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.69, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.11, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.73, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.63, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.61, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.96, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.5, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.88, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.77, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.32, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.61, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.61, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.96, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.34, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.42, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.32, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.5, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.17, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.34, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BETAMETHASONE VALERATE 0.1 % EX LOTN", "drug_information": { "unit": "60.000000", "type": "UN" }, "code_information": [ { "code": "00168004160", "type": "NDC" } ], "standard_charges": [ { "minimum": 21.38, "maximum": 71.33, "gross_charge": 75.88, "discounted_cash": 41.73, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 44.01, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.43, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.7, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 64.27, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.08, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.42, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.45, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.38, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 71.33, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 66.77, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.38, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 64.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 56.91, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.73, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 51.6, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 71.33, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.41, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.43, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.32, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 56.91, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 66.77, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 44.01, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.43, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BETAMETHASONE VALERATE 0.1 % EX OINT", "drug_information": { "unit": "45.000000", "type": "GR" }, "code_information": [ { "code": "00472037145", "type": "NDC" } ], "standard_charges": [ { "minimum": 18.22, "maximum": 60.77, "gross_charge": 64.65, "discounted_cash": 35.56, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.5, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.3, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 51.72, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.76, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.81, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.03, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.73, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.66, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.77, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 56.89, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.22, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.95, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 48.49, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.78, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.96, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.77, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.62, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.3, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 51.4, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 48.49, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 56.89, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.5, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.3, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BETHANECHOL CHLORIDE 10 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687068901", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BETHANECHOL CHLORIDE 25 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00832051201", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BEVACIZUMAB (AVASTIN) INTRAVITREAL INJ (1.25 MG/0.05 ML)", "drug_information": { "unit": "0.050000", "type": "UN" }, "code_information": [ { "code": "50242006001", "type": "NDC" } ], "standard_charges": [ { "minimum": 763.57, "maximum": 2547.02, "gross_charge": 2709.6, "discounted_cash": 1490.28, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1571.57, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1479.44, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2167.68, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2295.03, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 788.49, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1300.61, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1623.05, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 1620.34, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2547.02, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2384.45, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 763.57, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2303.16, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2032.2, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 954.59, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1842.53, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2547.02, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2121.62, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1479.44, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2154.13, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2032.2, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2384.45, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1571.57, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1479.44, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BEVACIZUMAB 100 MG/4ML IV SOLN", "drug_information": { "unit": "4.000000", "type": "UN" }, "code_information": [ { "code": "50242006001_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 763.57, "maximum": 2547.02, "gross_charge": 2709.6, "discounted_cash": 1490.28, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1571.57, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1479.44, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2167.68, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2295.03, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 788.49, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1300.61, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1623.05, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 1620.34, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2547.02, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2384.45, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 763.57, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2303.16, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2032.2, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 954.59, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1842.53, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2547.02, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2121.62, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1479.44, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2154.13, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2032.2, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2384.45, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1571.57, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1479.44, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BEVACIZUMAB 400 MG/16ML IV SOLN", "drug_information": { "unit": "16.000000", "type": "UN" }, "code_information": [ { "code": "50242006101", "type": "NDC" } ], "standard_charges": [ { "minimum": 2290.7, "maximum": 7641.07, "gross_charge": 8128.8, "discounted_cash": 4470.84, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4714.7, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4438.32, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6503.04, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6885.09, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2365.48, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3901.82, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4869.15, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4861.02, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7641.07, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7153.34, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2290.7, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6909.48, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6096.6, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2863.78, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5527.58, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7641.07, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6364.85, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4438.32, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6462.4, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6096.6, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7153.34, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4714.7, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4438.32, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BEVACIZUMAB-AWWB 100 MG/4ML IV SOLN", "drug_information": { "unit": "4.000000", "type": "UN" }, "code_information": [ { "code": "55513020601", "type": "NDC" } ], "standard_charges": [ { "minimum": 14.52, "maximum": 2493.9, "gross_charge": 2653.08, "discounted_cash": 1459.19, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1538.79, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.52, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2122.46, 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Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1989.81, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 934.68, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1804.09, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2493.9, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2077.36, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2109.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1989.81, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2334.71, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1538.79, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.52, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "BEVACIZUMAB-AWWB 400 MG/16ML IV SOLN", "drug_information": { "unit": "16.000000", "type": "UN" }, "code_information": [ { "code": "55513020701", "type": "NDC" } ], "standard_charges": [ { "minimum": 14.52, "maximum": 7481.52, "gross_charge": 7959.06, "discounted_cash": 4377.48, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4616.25, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.52, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6367.25, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6741.32, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2316.09, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3820.35, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": 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"methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6765.2, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5969.3, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2803.98, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5412.16, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7481.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6231.94, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6327.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5969.3, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7003.97, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4616.25, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.52, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "BEVACIZUMAB-BVZR 100 MG/4ML IV SOLN", "drug_information": { "unit": "4.000000", "type": "UN" }, "code_information": [ { "code": "00069031501", "type": "NDC" } ], "standard_charges": [ { "minimum": 12.88, "maximum": 2022.43, "gross_charge": 2151.52, "discounted_cash": 1183.34, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1247.88, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.88, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1721.22, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1822.34, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 626.09, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1032.73, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1288.76, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 1286.61, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2022.43, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1893.34, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 606.3, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1828.79, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1613.64, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 757.98, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1463.03, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2022.43, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1684.64, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.39, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1710.46, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1613.64, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1893.34, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1247.88, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.88, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "BEVACIZUMAB-BVZR 25 MG/ML INTRALESIONAL INJ", "drug_information": { "unit": "4.000000", "type": "UN" }, "code_information": [ { "code": "00069031501_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 12.88, "maximum": 2022.43, "gross_charge": 2151.52, "discounted_cash": 1183.34, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1247.88, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.88, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1721.22, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1822.34, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 626.09, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1032.73, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1288.76, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 1286.61, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2022.43, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1893.34, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 606.3, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1828.79, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1613.64, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 757.98, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1463.03, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2022.43, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1684.64, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.39, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1710.46, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1613.64, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1893.34, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1247.88, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.88, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "BEVACIZUMAB-BVZR 400 MG/16ML IV SOLN", "drug_information": { "unit": "16.000000", "type": "UN" }, "code_information": [ { "code": "00069034201", "type": "NDC" } ], "standard_charges": [ { "minimum": 12.88, "maximum": 6067.26, "gross_charge": 6454.53, "discounted_cash": 3549.99, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3743.63, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.88, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5163.62, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5466.99, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1878.27, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3098.17, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3866.26, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 3859.81, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6067.26, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5679.99, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1818.89, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5486.35, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4840.9, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2273.93, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4389.08, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6067.26, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5053.9, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.39, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5131.35, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4840.9, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5679.99, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3743.63, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.88, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "BICALUTAMIDE 50 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "47335048583", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BICTEGRAVIR-EMTRICITAB-TENOFOV 50-200-25 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "61958250101", "type": "NDC" } ], "standard_charges": [ { "minimum": 126.96, "maximum": 423.51, "gross_charge": 450.54, "discounted_cash": 247.8, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 261.31, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 245.99, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 360.43, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 381.61, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 131.11, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 216.26, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 269.87, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 269.42, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 423.51, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 396.48, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 126.96, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 382.96, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 337.91, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 158.73, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 306.37, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 423.51, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 352.77, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 245.99, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 358.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 337.91, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 396.48, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 261.31, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 245.99, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Biliary endo perq dx w/speci", "code_information": [ { "code": "47552", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4599.32, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3406.9, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 23652.07, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 42922.24, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4599.32, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 42922.24, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Biliary endoscopy thru skin", "code_information": [ { "code": "47554", "type": "HCPCS" }, { "code": "47555", "type": "HCPCS" }, { "code": "47556", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 7674.11, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5684.53, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1926.87, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 22610.66, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 41027.4, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7674.11, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2601.27, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 41027.4, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BIMATOPROST 0.01 % OP SOLN", "drug_information": { "unit": "2.500000", "type": "UN" }, "code_information": [ { "code": "00023320503", "type": "NDC" } ], "standard_charges": [ { "minimum": 224.45, "maximum": 748.71, "gross_charge": 796.5, "discounted_cash": 438.08, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 461.97, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 434.89, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 637.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 674.64, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 231.78, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 382.32, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 477.1, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 476.31, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 748.71, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 700.92, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 224.45, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 677.03, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 597.38, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 280.61, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 541.62, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 748.71, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 623.66, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 434.89, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 633.22, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 597.38, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 700.92, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 461.97, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 434.89, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BIMATOPROST 10 MCG IO IMPL", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00023965201", "type": "NDC" } ], "standard_charges": [ { "minimum": 1679.81, "maximum": 5603.34, "gross_charge": 5961.0, "discounted_cash": 3278.55, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3457.38, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3254.71, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4768.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5048.97, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1734.65, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2861.28, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3570.64, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 3564.68, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5603.34, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5245.68, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1679.81, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5066.85, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4470.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2100.06, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4053.48, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5603.34, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4667.46, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3254.71, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4739.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4470.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5245.68, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3457.38, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3254.71, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Biopsy abdominal mass", "code_information": [ { "code": "49180", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1194.28, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 884.65, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 4671.33, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 8476.2, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1194.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 8476.2, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Biopsy arm/elbow soft tissue", "code_information": [ { "code": "24065", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1194.28, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 884.65, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 8008.41, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 14531.4, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1194.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 14531.4, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Biopsy eye muscle", "code_information": [ { "code": "67346", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2779.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2058.97, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 8938.39, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 18090.9, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2779.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 18090.9, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Biopsy eyelid & lid margin", "code_information": [ { "code": "67810", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 220.34, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 1264.8, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 2295.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 220.34, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 2295.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Biopsy finger joint lining", "code_information": [ { "code": "26110", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1179.66, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 873.82, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 6284.82, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 11403.9, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1179.66, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 11403.9, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Biopsy muscle perq needle", "code_information": [ { "code": "20206", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1194.28, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 884.65, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 4154.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 7537.5, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1194.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 7537.5, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Biopsy of breast open", "code_information": [ { "code": "19101", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2822.56, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2090.79, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 5573.86, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 10113.86, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2822.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 10113.86, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Biopsy of cervix", "code_information": [ { "code": "57500", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 641.82, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 475.42, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 10639.2, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 19886.23, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 641.82, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 19886.23, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Biopsy of cervix w/scope", "code_information": [ { "code": "57455", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 224.22, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 1197.34, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 2172.6, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 224.22, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 2172.6, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Biopsy of cornea", "code_information": [ { "code": "65410", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1719.62, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1273.8, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 5077.23, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 9212.72, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1719.62, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 9212.72, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Biopsy of external ear", "code_information": [ { "code": "69100", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 171.17, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 1815.35, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 3294.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 171.17, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 3294.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Biopsy of external ear canal", "code_information": [ { "code": "69105", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1091.85, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 808.78, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 4179.4, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 7583.58, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1091.85, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 7583.58, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Biopsy of eyelid lining", "code_information": [ { "code": "68100", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1719.62, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1273.8, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 8575.93, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 15561.16, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1719.62, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 15561.16, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Biopsy of floor of mouth", "code_information": [ { "code": "41108", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1194.28, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 884.65, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 5750.63, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 10434.6, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1194.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 10434.6, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Biopsy of heart lining", "code_information": [ { "code": "93505", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2320.02, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1718.54, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 7780.21, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 14117.31, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2320.02, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 14117.31, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Biopsy of lip", "code_information": [ { "code": "40490", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 171.17, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 1433.44, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 2601.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 171.17, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 2601.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Biopsy of neck/chest", "code_information": [ { "code": "21550", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1194.28, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 884.65, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 13756.22, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 24960.94, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1194.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 24960.94, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Biopsy of nerve", "code_information": [ { "code": "64795", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1439.39, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1066.21, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 40428.71, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 73358.57, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1439.39, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 73358.57, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Biopsy of ovary(s)", "code_information": [ { "code": "58900", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2343.63, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1736.02, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 18671.01, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 33878.85, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2343.63, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 33878.85, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Biopsy of penis", "code_information": [ { "code": "54100", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1194.28, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 4434.24, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 8046.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1194.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 8046.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Biopsy of prostate", "code_information": [ { "code": "55700", "type": "HCPCS" }, { "code": "55705", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2542.24, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1118.49, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1883.14, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 4651.36, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 8439.98, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1509.96, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2542.24, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 8439.98, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Biopsy of rectum", "code_information": [ { "code": "45100", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2021.42, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1497.34, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 7288.11, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 13227.98, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2021.42, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 13227.98, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Biopsy of salivary gland", "code_information": [ { "code": "42400", "type": "HCPCS" }, { "code": "42405", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1091.85, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 384.16, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 808.78, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 2623.84, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 4761.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 518.62, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1091.85, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 4761.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Biopsy of soft tissues", "code_information": [ { "code": "27040", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1194.28, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 884.65, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 6486.06, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 11769.06, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1194.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 11769.06, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Biopsy of tear gland", "code_information": [ { "code": "68510", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1719.62, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1273.8, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 5964.99, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 10823.56, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1719.62, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 10823.56, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Biopsy of tear sac", "code_information": [ { "code": "68525", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1719.62, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1273.8, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 10308.85, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 18705.59, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1719.62, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 18705.59, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Biopsy of testis", "code_information": [ { "code": "54500", "type": "HCPCS" }, { "code": "54505", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2542.24, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1562.68, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1883.14, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 11837.67, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 21479.65, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2109.62, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2542.24, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 21479.65, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Biopsy of throat", "code_information": [ { "code": "42800", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1091.85, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 808.78, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 12772.25, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 23175.45, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1091.85, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 23175.45, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Biopsy of thyroid", "code_information": [ { "code": "60100", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 518.62, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 384.16, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 3412.48, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 6192.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 518.62, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 6192.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Biopsy of tongue", "code_information": [ { "code": "41100", "type": "HCPCS" }, { "code": "41105", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2390.47, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 278.05, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1770.72, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 9266.83, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 17655.89, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 375.37, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2390.47, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 17655.89, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Biopsy of upper nose/throat", "code_information": [ { "code": "42804", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2390.47, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1770.72, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 18660.65, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 33860.03, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2390.47, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 33860.03, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Biopsy of uterus lining", "code_information": [ { "code": "58100", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 148.28, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 1038.62, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 1884.6, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 148.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 1884.6, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Biopsy of vagina", "code_information": [ { "code": "57100", "type": "HCPCS" }, { "code": "57105", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2343.63, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 475.42, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1736.02, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 6728.94, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 12209.77, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 641.82, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2343.63, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 12209.77, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Biopsy of vulva/perineum", "code_information": [ { "code": "56605", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 641.82, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 475.42, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 3483.9, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 6321.6, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 641.82, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 6321.6, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Biopsy roof of mouth", "code_information": [ { "code": "42100", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1091.85, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 808.78, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 17921.78, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 32519.35, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1091.85, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 32519.35, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Biopsy shoulder tissues", "code_information": [ { "code": "23065", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1194.28, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 884.65, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 9267.66, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 16816.33, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1194.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 16816.33, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Biopsy thigh soft tissues", "code_information": [ { "code": "27324", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2109.62, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1562.68, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 17929.42, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 33540.3, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2109.62, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 33540.3, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Biopsy/removal lymph nodes", "code_information": [ { "code": "38500", "type": "HCPCS" }, { "code": "38510", "type": "HCPCS" }, { "code": "38520", "type": "HCPCS" }, { "code": "38525", "type": "HCPCS" }, { "code": "38530", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2822.56, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2090.79, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 12271.04, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 24431.4, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2822.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 24431.4, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BIOTENE DRY MOUTH MT LIQD", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "R4858200440", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BIOTIN 1000 MCG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "54629398501", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BIOTIN 5 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "40985027116", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BIOTIN 5 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "54022107501", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BIOTIN 5 MG PO TBDP", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "40093010118", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BISACODYL 10 MG RE SUPP", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00574705050", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BISACODYL 10 MG/30ML RE ENEM", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00132070336", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.24, "maximum": 4.14, "gross_charge": 4.4, "discounted_cash": 2.42, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.55, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.73, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.28, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.11, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.64, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.63, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.14, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.87, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.24, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.74, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.3, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.55, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.99, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.14, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.45, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.5, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.3, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.87, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.55, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BISACODYL 5 MG PO TBEC", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00904640761", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BISMUTH SUBSALICYLATE 262 MG PO CHEW", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "46122070165", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BISMUTH SUBSALICYLATE 262 MG/15ML PO SUSP", "drug_information": { "unit": "15.000000", "type": "UN" }, "code_information": [ { "code": "00536128636", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BISOPROLOL FUMARATE 10 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "29300012713", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BISOPROLOL FUMARATE 5 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "29300012613", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BIVALIRUDIN TRIFLUOROACETATE 250 MG IV SOLR", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "16729027567", "type": "NDC" } ], "standard_charges": [ { "minimum": 54.81, "maximum": 182.84, "gross_charge": 194.51, "discounted_cash": 106.98, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 112.82, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 106.2, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 155.61, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 164.75, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 56.6, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.36, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 116.51, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 116.32, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 182.84, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 171.17, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.81, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 165.33, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 145.88, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 68.53, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 132.27, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 182.84, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 152.3, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 106.2, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 154.64, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 145.88, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 171.17, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 112.82, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 106.2, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BLEOMYCIN 9 UNITS/ML SYRINGE FOR CHEMOEMBOLIZATION", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "71288010610_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 34.41, "maximum": 114.77, "gross_charge": 122.1, "discounted_cash": 67.16, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 70.82, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 66.67, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 97.68, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.42, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.53, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 58.61, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 73.14, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 73.02, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 114.77, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 107.45, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.41, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.79, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 91.58, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.02, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 83.03, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 114.77, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 95.6, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 66.67, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 97.07, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 91.58, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 107.45, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 70.82, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 66.67, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BLEOMYCIN CHEMO OPHTHALMIC SYRINGE", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "08252000063", "type": "NDC" } ], "standard_charges": [ { "minimum": 33.51, "maximum": 111.79, "gross_charge": 118.93, "discounted_cash": 65.41, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 68.98, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 64.94, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 95.14, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 100.73, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.61, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 57.09, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 71.24, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 71.12, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 111.79, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 104.66, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.51, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 101.09, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 89.2, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.9, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 80.87, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 111.79, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.12, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 64.94, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 94.55, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 89.2, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 104.66, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 68.98, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 64.94, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BLEOMYCIN CHEMO SYRINGE", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "71288010610_3", "type": "NDC" } ], "standard_charges": [ { "minimum": 34.41, "maximum": 114.77, "gross_charge": 122.1, "discounted_cash": 67.16, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 70.82, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 66.67, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 97.68, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.42, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.53, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 58.61, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 73.14, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 73.02, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 114.77, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 107.45, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.41, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.79, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 91.58, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.02, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 83.03, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 114.77, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 95.6, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 66.67, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 97.07, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 91.58, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 107.45, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 70.82, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 66.67, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BLEOMYCIN SULFATE 15 UNITS IJ SOLR", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "71288010610", "type": "NDC" } ], "standard_charges": [ { "minimum": 14.68, "maximum": 48.97, "gross_charge": 52.1, "discounted_cash": 28.66, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.22, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.45, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.68, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 44.13, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.01, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.21, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.16, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 48.97, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.85, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.68, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 44.29, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.08, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.35, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.43, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 48.97, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.79, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.45, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.42, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.08, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.85, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.22, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.45, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BLINATUMOMAB 35 MCG IV SOLR", "drug_information": { "unit": "2.800000", "type": "UN" }, "code_information": [ { "code": "55513016001", "type": "NDC" } ], "standard_charges": [ { "minimum": 83.09, "maximum": 14509.35, "gross_charge": 15435.48, "discounted_cash": 8489.51, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 8952.58, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 83.09, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12348.38, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13073.85, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4491.72, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7409.03, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 9245.85, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 9230.42, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14509.35, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13583.22, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 4349.72, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13120.16, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11576.61, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 5437.92, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 10496.13, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 14509.35, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 12085.98, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 112.17, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 12271.21, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11576.61, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13583.22, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8952.58, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 83.09, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "Bone biopsy open deep", "code_information": [ { "code": "20245", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2109.62, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1562.68, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 5113.09, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 9277.78, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2109.62, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 9277.78, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Bone biopsy open superficial", "code_information": [ { "code": "20240", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2109.62, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1562.68, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 5012.08, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 9094.5, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2109.62, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 9094.5, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Bone biopsy trocar/ndl deep", "code_information": [ { "code": "20225", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1194.28, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 884.65, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 5724.34, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 10386.9, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1194.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 10386.9, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Bone biopsy trocar/ndl supfc", "code_information": [ { "code": "20220", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1194.28, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 884.65, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 4486.32, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 8140.5, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1194.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 8140.5, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Bone marrow harvest autolog", "code_information": [ { "code": "38232", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 3453.44, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2558.1, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 18908.96, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 34310.62, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3453.44, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 34310.62, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BONNEYS BLUE DYE 2%", "drug_information": { "unit": "30.000000", "type": "UN" }, "code_information": [ { "code": "08252043030", "type": "NDC" } ], "standard_charges": [ { "minimum": 8.07, "maximum": 26.93, "gross_charge": 28.65, "discounted_cash": 15.76, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.62, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.64, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.92, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.27, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.34, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.75, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.16, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.13, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.93, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.21, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.07, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.35, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.49, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.48, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.93, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.43, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.64, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.78, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.49, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.21, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.62, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.64, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BORTEZOMIB 3.5 MG IJ SOLR", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "71288011810", "type": "NDC" } ], "standard_charges": [ { "minimum": 12.77, "maximum": 42.58, "gross_charge": 45.3, "discounted_cash": 24.92, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.27, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.73, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.24, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.37, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.18, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.74, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.13, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.09, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.58, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.86, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.77, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.51, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.98, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.96, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.58, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.47, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.73, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.01, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.98, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.86, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.27, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.73, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BORTEZOMIB CHEMO IV SYRINGE", "drug_information": { "unit": "3.500000", "type": "UN" }, "code_information": [ { "code": "71288011810_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 12.77, "maximum": 42.58, "gross_charge": 45.3, "discounted_cash": 24.92, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.27, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.73, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.24, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.37, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.18, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.74, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.13, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.09, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.58, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.86, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.77, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.51, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.98, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.96, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.58, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.47, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.73, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.01, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.98, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.86, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.27, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.73, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BORTEZOMIB CHEMO SC SYRINGE", "drug_information": { "unit": "1.400000", "type": "UN" }, "code_information": [ { "code": "71288011810_3", "type": "NDC" } ], "standard_charges": [ { "minimum": 12.77, "maximum": 42.58, "gross_charge": 45.3, "discounted_cash": 24.92, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.27, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.73, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.24, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.37, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.18, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.74, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.13, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.09, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.58, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.86, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.77, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.51, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.98, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.96, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.58, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.47, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.73, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.01, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.98, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.86, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.27, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.73, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BOSENTAN 125 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68382044714", "type": "NDC" } ], "standard_charges": [ { "minimum": 10.57, "maximum": 35.27, "gross_charge": 37.52, "discounted_cash": 20.64, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.76, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.49, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.02, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.78, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.92, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.01, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.47, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.44, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.27, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.02, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.57, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.89, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.14, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.22, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.51, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.27, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.38, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.49, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.83, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.14, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.02, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.76, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.49, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BOSENTAN 6.25 MG/ML ORAL SUSPENSION", "drug_information": { "unit": "20.000000", "type": "UN" }, "code_information": [ { "code": "08252000080", "type": "NDC" } ], "standard_charges": [ { "minimum": 12.35, "maximum": 41.19, "gross_charge": 43.82, "discounted_cash": 24.1, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.42, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.93, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.06, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.12, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.75, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.03, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.25, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.2, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.19, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.56, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.35, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.25, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.87, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.44, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.19, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.31, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.93, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.84, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.87, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.56, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.42, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.93, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BOSENTAN 62.5 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68382044614", "type": "NDC" } ], "standard_charges": [ { "minimum": 10.27, "maximum": 34.24, "gross_charge": 36.43, "discounted_cash": 20.04, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.13, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.89, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.14, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.86, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.6, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.49, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.82, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.79, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.24, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.06, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.97, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.32, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.83, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.77, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.24, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.52, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.89, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.96, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.32, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.06, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.13, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.89, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BOSUTINIB 500 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00069013601", "type": "NDC" } ], "standard_charges": [ { "minimum": 588.88, "maximum": 1964.34, "gross_charge": 2089.72, "discounted_cash": 1149.35, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1212.04, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1140.99, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1671.78, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1769.99, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 608.11, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1003.07, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1251.74, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 1249.65, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1964.34, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1838.95, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 588.88, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1776.26, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1567.29, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 736.21, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1421.01, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1964.34, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1636.25, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1140.99, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1661.33, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1567.29, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1838.95, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1212.04, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1140.99, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BOTULISM IMMUNE GLOBULIN HUMAN 100 MG IV SOLR", "drug_information": { "unit": "2.000000", "type": "UN" }, "code_information": [ { "code": "68403110006", "type": "NDC" } ], "standard_charges": [ { "minimum": 1158.0, "maximum": 42582.0, "gross_charge": 45300.0, "discounted_cash": 24915.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 26274.0, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 24733.8, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39320.4, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13182.3, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21744.0, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27134.7, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 11394.0, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42582.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39864.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 12765.54, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38505.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33975.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 15959.19, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 30804.0, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 42582.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 35469.9, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24733.8, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 15189.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33975.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39864.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 26274.0, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24733.8, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Brain canal shunt procedure", "code_information": [ { "code": "61070", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 510.46, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 378.12, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 16379.03, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 29766.83, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 510.46, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 29766.83, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Breast augmentation w/implt", "code_information": [ { "code": "19325", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 7053.35, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5224.7, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 17483.86, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 31724.75, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7053.35, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 31724.75, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Breast reconstruction", "code_information": [ { "code": "19350", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2822.56, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2090.79, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 18257.02, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 33127.66, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2822.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 33127.66, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Breast reduction", "code_information": [ { "code": "19318", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4806.97, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3560.72, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 16860.8, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 30594.18, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4806.97, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 30594.18, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BRENTUXIMAB VEDOTIN 50 MG IV SOLR", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "51144005001", "type": "NDC" } ], "standard_charges": [ { "minimum": 130.96, "maximum": 33112.44, "gross_charge": 35226.0, "discounted_cash": 19374.3, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 20431.08, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 130.96, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 28180.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 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of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 12410.12, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23953.68, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 33112.44, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 27581.96, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", 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"Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 130.96, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "BREXPIPRAZOLE 3 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "59148003913", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.3, "maximum": 104.41, "gross_charge": 111.07, "discounted_cash": 61.09, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 64.42, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.64, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs 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85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 83.3, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.13, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.53, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 104.41, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.97, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.64, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.3, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 83.3, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 97.74, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 64.42, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.64, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BRILLIANT BLUE G 0.025 % IO SOSY", "drug_information": { "unit": "0.500000", "type": "UN" }, "code_information": [ { "code": "68803072225", "type": "NDC" } ], "standard_charges": [ { "minimum": 138.08, "maximum": 1158.0, "gross_charge": 490.0, "discounted_cash": 269.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 284.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 267.54, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 425.32, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 142.59, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 235.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 293.51, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 293.02, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 460.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 431.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 138.08, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 416.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 367.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 172.63, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 333.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue 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billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 431.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 284.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 267.54, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BRIMONIDINE TARTRATE 0.1 % OP SOLN", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "00023932105", "type": "NDC" } ], "standard_charges": [ { "minimum": 173.61, "maximum": 579.11, "gross_charge": 616.07, "discounted_cash": 338.84, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 357.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 336.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 492.86, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 521.81, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 179.28, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 295.71, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 369.03, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 368.41, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 579.11, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 542.14, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 173.61, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 523.66, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 462.05, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 217.04, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 418.93, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 579.11, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 482.38, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 336.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 489.78, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 462.05, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 542.14, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 357.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 336.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BRIMONIDINE TARTRATE 0.15 % OP SOLN", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "61314014405", "type": "NDC" } ], "standard_charges": [ { "minimum": 117.74, "maximum": 392.76, "gross_charge": 417.83, "discounted_cash": 229.81, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 242.34, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 228.14, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 334.26, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 353.9, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 121.59, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 200.56, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 250.28, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 249.86, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 392.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 367.69, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 117.74, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 355.16, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 313.37, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 147.2, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 284.12, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 392.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 327.16, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { 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"methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 228.14, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BRIMONIDINE TARTRATE 0.2 % OP SOLN", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "70069023101", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BRIMONIDINE TARTRATE-TIMOLOL 0.2-0.5 % OP SOLN", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "00023921105", "type": "NDC" } ], "standard_charges": [ { "minimum": 182.26, "maximum": 607.96, "gross_charge": 646.77, "discounted_cash": 355.72, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 375.13, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 353.14, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 517.42, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 547.81, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 188.21, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 310.45, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 387.42, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 386.77, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 607.96, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 569.16, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 182.26, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 549.75, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 485.08, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 227.86, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 439.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 607.96, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 506.42, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 353.14, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 514.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 485.08, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 569.16, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 375.13, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 353.14, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BRIVARACETAM 10 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "R5047437066", "type": "NDC" } ], "standard_charges": [ { "minimum": 12.9, "maximum": 43.01, "gross_charge": 45.76, "discounted_cash": 25.17, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.54, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.98, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.61, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.76, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.32, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.96, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.41, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.36, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.01, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.27, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.9, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.9, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.32, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.12, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.12, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.01, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.83, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.98, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.38, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.32, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.27, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.54, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.98, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BRIVARACETAM 10 MG/ML PO SOLN", "drug_information": { "unit": "2.500000", "type": "UN" }, "code_information": [ { "code": "50474087015", "type": "NDC" } ], "standard_charges": [ { "minimum": 7.64, "maximum": 25.49, "gross_charge": 27.12, "discounted_cash": 14.92, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.73, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.81, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.7, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.97, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.89, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.02, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.24, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.22, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.49, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.87, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.64, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.05, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.34, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.55, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.44, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.49, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.23, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.81, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.56, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.34, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.87, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.73, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.81, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BRIVARACETAM 100 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "50474077009", "type": "NDC" } ], "standard_charges": [ { "minimum": 15.28, "maximum": 50.98, "gross_charge": 54.23, "discounted_cash": 29.83, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.45, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.61, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.38, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.93, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.78, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.03, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.48, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.43, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.98, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.72, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.28, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.1, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.67, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.11, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.88, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.98, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.46, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.61, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.11, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.67, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.72, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.45, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.61, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BRIVARACETAM 25 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "50474047009", "type": "NDC" } ], "standard_charges": [ { "minimum": 15.28, "maximum": 50.98, "gross_charge": 54.23, "discounted_cash": 29.83, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.45, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.61, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.38, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.93, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.78, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.03, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.48, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.43, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.98, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.72, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.28, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.1, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.67, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.11, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.88, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.98, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.46, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.61, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.11, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.67, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.72, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.45, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.61, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BRIVARACETAM 50 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "50474057066", "type": "NDC" } ], "standard_charges": [ { "minimum": 15.28, "maximum": 50.98, "gross_charge": 54.23, "discounted_cash": 29.83, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.45, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.61, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.38, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.93, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.78, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.03, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.48, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.43, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.98, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.72, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.28, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.1, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.67, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.11, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.88, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.98, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.46, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.61, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.11, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.67, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.72, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.45, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.61, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BRIVARACETAM 50 MG/5ML IV SOLN", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "50474097075", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Brnchsc w/ther aspir 1st", "code_information": [ { "code": "31645", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1271.11, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 941.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 13676.5, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 24816.24, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1271.11, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 24816.24, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BROMFENAC SODIUM (ONCE-DAILY) 0.09 % OP SOLN", "drug_information": { "unit": "2.000000", "type": "UN" }, "code_information": [ { "code": "72266014201", "type": "NDC" } ], "standard_charges": [ { "minimum": 24.97, "maximum": 83.28, "gross_charge": 88.6, "discounted_cash": 48.73, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 51.39, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 48.38, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 70.88, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.04, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.78, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.53, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 53.07, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.98, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 83.28, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 77.97, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.97, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.31, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 66.45, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.21, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.25, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 83.28, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 69.37, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 48.38, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 70.44, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 66.45, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 77.97, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 51.39, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 48.38, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BROMFENAC SODIUM 0.07 % OP SOLN", "drug_information": { "unit": "3.000000", "type": "UN" }, "code_information": [ { "code": "24208060203", "type": "NDC" } ], "standard_charges": [ { "minimum": 364.33, "maximum": 1215.31, "gross_charge": 1292.88, "discounted_cash": 711.08, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 749.87, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 705.91, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1034.3, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1095.07, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 376.23, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 620.58, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 774.44, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 773.14, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1215.31, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1137.73, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 364.33, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1098.95, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 969.66, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 455.48, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 879.16, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1215.31, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1012.33, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 705.91, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1027.84, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 969.66, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1137.73, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 749.87, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 705.91, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BROMOCRIPTINE MESYLATE 2.5 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "R0781532501", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BROMOCRIPTINE MESYLATE 5 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00378709693", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.79, "maximum": 5.97, "gross_charge": 6.35, "discounted_cash": 3.49, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.68, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.47, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.08, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.38, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.85, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.05, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.8, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.8, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.97, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.59, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.79, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.76, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.24, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.32, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.97, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.97, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.47, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.05, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.76, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.59, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.68, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.47, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Bronch ebus samplng 1/2 node", "code_information": [ { "code": "31652", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2717.65, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2013.07, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 15314.58, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 27788.54, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2717.65, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 27788.54, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Bronch ebus samplng 3/> node", "code_information": [ { "code": "31653", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2717.65, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2013.07, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 16102.59, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 29218.42, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2717.65, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 29218.42, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Bronch thermoplsty 1 lobe", "code_information": [ { "code": "31660", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 5102.55, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3779.67, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 18996.08, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 34468.8, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5102.55, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 34468.8, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Bronch thermoplsty 2/> lobes", "code_information": [ { "code": "31661", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 5102.55, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3779.67, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 14280.3, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 25911.84, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5102.55, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 25911.84, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Bronch w/balloon occlusion", "code_information": [ { "code": "31634", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 5102.55, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3779.67, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 17699.69, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 32116.38, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5102.55, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 32116.38, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Bronchial valve init insert", "code_information": [ { "code": "31647", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 5102.55, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3779.67, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 34148.27, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 61962.74, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5102.55, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 61962.74, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Bronchial valve remov init", "code_information": [ { "code": "31648", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2717.65, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2013.07, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 8105.21, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 14707.04, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2717.65, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 14707.04, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Bronchoscopy bronch stents", "code_information": [ { "code": "31636", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 5102.55, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3779.67, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 15011.42, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 27238.48, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5102.55, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 27238.48, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Bronchoscopy dilate w/stent", "code_information": [ { "code": "31631", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 5102.55, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3779.67, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 16718.35, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 30335.81, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5102.55, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 30335.81, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Bronchoscopy dilate/fx repr", "code_information": [ { "code": "31630", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2717.65, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2013.07, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 8973.33, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 16282.29, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2717.65, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 16282.29, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Bronchoscopy revise stent", "code_information": [ { "code": "31638", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 5102.55, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3779.67, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 8368.74, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 15185.24, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5102.55, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 15185.24, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Bronchoscopy treat blockage", "code_information": [ { "code": "31641", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2717.65, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2013.07, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 10722.21, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 19455.69, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2717.65, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 19455.69, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Bronchoscopy w/biopsy(s)", "code_information": [ { "code": "31625", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1271.11, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 941.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 11804.6, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 21419.68, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1271.11, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 21419.68, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Bronchoscopy w/fb removal", "code_information": [ { "code": "31635", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1271.11, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 941.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 10780.28, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 19561.03, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1271.11, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 19561.03, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Bronchoscopy w/markers", "code_information": [ { "code": "31626", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 5102.55, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3779.67, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 10298.27, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 18686.38, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5102.55, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 18686.38, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Bronchoscopy w/tumor excise", "code_information": [ { "code": "31640", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2717.65, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2013.07, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 10897.53, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 19773.76, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2717.65, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 19773.76, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Bronchoscopy/lung bx each", "code_information": [ { "code": "31628", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2717.65, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2013.07, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 14320.6, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 25984.94, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2717.65, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 25984.94, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Bronchoscopy/needle bx each", "code_information": [ { "code": "31629", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2717.65, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2013.07, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 15685.94, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 28462.41, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2717.65, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 28462.41, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Brst rcnstj free flap", "code_information": [ { "code": "19364", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 15971.94, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 28981.37, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 28981.37, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BSS IO SOLN", "drug_information": { "unit": "15.000000", "type": "UN" }, "code_information": [ { "code": "00065079515", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 1158.0, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.72, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BSS IO SOLN 15ML (BULK CHARGE)", "drug_information": { "unit": "15.000000", "type": "UN" }, "code_information": [ { "code": "00065079515_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 1158.0, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.72, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BSS PLUS IO SOLN", "drug_information": { "unit": "500.000000", "type": "UN" }, "code_information": [ { "code": "00065080050", "type": "NDC" } ], "standard_charges": [ { "minimum": 52.59, "maximum": 1158.0, "gross_charge": 186.61, "discounted_cash": 102.64, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 108.23, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 101.89, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 161.98, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.3, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 89.57, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 111.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 111.59, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 175.41, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 164.22, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.59, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 158.62, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 139.96, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.74, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 126.89, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 175.41, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 146.12, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 101.89, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 148.35, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 139.96, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 164.22, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 108.23, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 101.89, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BUDESONIDE 0.25 MG/2ML IN SUSP", "drug_information": { "unit": "2.000000", "type": "UN" }, "code_information": [ { "code": "00487960101", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.15, "maximum": 7.16, "gross_charge": 7.62, "discounted_cash": 4.19, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.42, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.16, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.1, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.45, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.22, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.66, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.56, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.56, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.16, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.71, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.15, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.48, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.72, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.68, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.18, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.16, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.97, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.16, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.06, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.72, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.71, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.42, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.16, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BUDESONIDE 0.5 MG/2ML IN SUSP", "drug_information": { "unit": "2.000000", "type": "UN" }, "code_information": [ { "code": "60687052483", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.01, "maximum": 6.71, "gross_charge": 7.14, "discounted_cash": 3.93, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.14, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.9, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.71, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.05, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.08, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.43, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.28, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.27, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.71, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.28, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.01, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.07, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.36, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.52, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.86, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.71, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.59, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.9, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.68, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.36, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.28, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.14, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.9, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BUDESONIDE 1 MG/2ML IN SUSP", "drug_information": { "unit": "2.000000", "type": "UN" }, "code_information": [ { "code": "69097032187", "type": "NDC" } ], "standard_charges": [ { "minimum": 4.02, "maximum": 13.41, "gross_charge": 14.27, "discounted_cash": 7.85, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.28, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.79, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.42, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.09, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.15, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.85, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.55, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.53, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.41, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.56, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.02, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.13, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.7, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.03, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.7, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.41, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.17, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.79, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.34, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.7, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.56, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.28, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.79, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BUDESONIDE 180 MCG/ACT IN AEPB", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "61269051812", "type": "NDC" } ], "standard_charges": [ { "minimum": 236.37, "maximum": 788.45, "gross_charge": 838.78, "discounted_cash": 461.33, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 486.49, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 457.97, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 671.02, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 710.45, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 244.08, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 402.61, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 502.43, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 501.59, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 788.45, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 738.13, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 236.37, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 712.96, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 629.09, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 295.5, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 570.37, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 788.45, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 656.76, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 457.97, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 666.83, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 629.09, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 738.13, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 486.49, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 457.97, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BUDESONIDE 3 MG PO CPEP", "drug_information": { "unit": "2.000000", "type": "UN" }, "code_information": [ { "code": "60687059632", "type": "NDC" } ], "standard_charges": [ { "minimum": 9.16, "maximum": 30.55, "gross_charge": 32.5, "discounted_cash": 17.88, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.85, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.75, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.53, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.46, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.47, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.44, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.55, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.16, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.63, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.38, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.45, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.1, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.55, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.45, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.75, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.84, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.38, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.85, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.75, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BUDESONIDE 90 MCG/ACT IN AEPB", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00186091706", "type": "NDC" } ], "standard_charges": [ { "minimum": 176.21, "maximum": 587.79, "gross_charge": 625.31, "discounted_cash": 343.92, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 362.68, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 341.42, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 500.25, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 529.64, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 181.97, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 300.15, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 374.56, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 373.94, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 587.79, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 550.27, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 176.21, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 531.51, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 468.98, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 220.3, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 425.21, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 587.79, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 489.62, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 341.42, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 497.12, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 468.98, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 550.27, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 362.68, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 341.42, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BUDESONIDE-FORMOTEROL FUMARATE 160-4.5 MCG/ACT IN AERO", "drug_information": { "unit": "6.000000", "type": "GR" }, "code_information": [ { "code": "00186037028", "type": "NDC" } ], "standard_charges": [ { "minimum": 38.93, "maximum": 129.86, "gross_charge": 138.15, "discounted_cash": 75.98, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 80.13, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.43, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 110.52, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 117.01, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.2, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 66.31, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.75, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.61, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 129.86, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 121.57, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.93, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 117.43, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.61, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 48.67, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.94, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 129.86, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 108.17, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.43, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 109.83, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.61, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 121.57, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 80.13, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.43, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BUDESONIDE-FORMOTEROL FUMARATE 80-4.5 MCG/ACT IN AERO", "drug_information": { "unit": "7.000000", "type": "GR" }, "code_information": [ { "code": "00186037228", "type": "NDC" } ], "standard_charges": [ { "minimum": 77.86, "maximum": 259.72, "gross_charge": 276.3, "discounted_cash": 151.97, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 160.25, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 150.86, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 221.04, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 234.03, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 80.4, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 132.62, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 165.5, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 165.23, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 259.72, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 243.14, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 77.86, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 234.86, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 207.23, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 97.34, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 187.88, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 259.72, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 216.34, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 150.86, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 219.66, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 207.23, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 243.14, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 160.25, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 150.86, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BUMETANIDE 0.25 MG/ML IJ SOLN", "drug_information": { "unit": "4.000000", "type": "UN" }, "code_information": [ { "code": "68462046954_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BUMETANIDE 0.25 MG/ML IJ SOLN|DISCARDED DRUG NOT ADMINISTERED", "drug_information": { "unit": "4.000000", "type": "UN" }, "code_information": [ { "code": "68462046954", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.02, "maximum": 3.41, "gross_charge": 3.63, "discounted_cash": 2.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.11, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.98, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.9, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.07, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.06, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.74, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.17, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.17, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.41, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.19, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.02, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.09, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.28, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.47, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.41, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.84, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.98, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.89, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.19, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.11, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.98, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BUMETANIDE 0.5 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "50268013015", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BUMETANIDE 1 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687038401", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BUPIVACAINE 0.25 % INFUSION", "drug_information": { "unit": "60.000000", "type": "UN" }, "code_information": [ { "code": "00409155930_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BUPIVACAINE 0.25 % INFUSION|DISCARDED DRUG NOT ADMINISTERED", "drug_information": { "unit": "60.000000", "type": "UN" }, "code_information": [ { "code": "00409155930", "type": "NDC" } ], "standard_charges": [ { "minimum": 5.58, "maximum": 18.6, "gross_charge": 19.79, "discounted_cash": 10.88, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.48, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.81, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.83, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.76, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.76, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.5, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.85, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.83, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.42, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.58, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.82, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.84, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.97, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.46, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.5, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.81, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.73, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.84, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.42, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.48, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.81, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BUPIVACAINE 0.75% 10 ML SDV (BULK CHARGE)", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "00409158210_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BUPIVACAINE 0.75% 10 ML SDV (BULK CHARGE)|DISCARDED DRUG NOT ADMINISTERED", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "00409158210", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.64, "maximum": 8.82, "gross_charge": 9.38, "discounted_cash": 5.16, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.44, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.12, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.5, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.94, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.73, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.5, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.62, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.61, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.82, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.25, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.64, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.97, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.3, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.38, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.82, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.34, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.12, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.46, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.25, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.44, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.12, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BUPIVACAINE HCL (PF) 0.25 % IJ SOLN", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "00409115902", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - 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"Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BUPIVACAINE HCL (PF) 0.25% IJ SOLN 30ML VIAL (BULK CHARGE)", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "55150016830", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, 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34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": 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charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BUPIVACAINE HCL (PF) 0.5 % IJ SOLN", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "00409116201", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, 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"additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BUPIVACAINE HCL (PF) 0.5 % IJ SOLN 30ML VIAL (BULK CHARGE)", "drug_information": { "unit": "30.000000", "type": "UN" }, "code_information": [ { "code": "00409116202_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BUPIVACAINE HCL (PF) 0.5 % IJ SOLN 30ML VIAL (BULK CHARGE)|DISCARDED DRUG NOT ADMINISTERED", "drug_information": { "unit": "30.000000", "type": "UN" }, "code_information": [ { "code": "00409116202", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.31, "maximum": 4.37, "gross_charge": 4.65, "discounted_cash": 2.56, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.7, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.54, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.72, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.94, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.35, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.23, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.79, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.09, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.31, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.95, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.49, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.64, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.16, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.64, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.54, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.7, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.49, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.09, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.7, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.54, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BUPIVACAINE HCL (PF) 0.75 % IJ SOLN", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "00409158210_3", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All 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charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", 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"additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BUPIVACAINE HCL 0.5 % IJ SOLN", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "00409161050", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BUPIVACAINE IN DEXTROSE 0.75-8.25 % IT SOLN", "drug_information": { "unit": "2.000000", "type": "UN" }, "code_information": [ { "code": "00409176110", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BUPIVACAINE LIPOSOME 1.3 % IJ SUSP", "drug_information": { "unit": "20.000000", "type": "UN" }, "code_information": [ { "code": "65250026609", "type": "NDC" } ], "standard_charges": [ { "minimum": 378.69, "maximum": 1263.18, "gross_charge": 1343.81, "discounted_cash": 739.1, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 779.41, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 733.72, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1075.05, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1138.21, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 391.05, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 645.03, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 804.94, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue 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"payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BUPIVACAINE-EPINEPHRINE 0.5%-5MG/ML 30 ML (BULK CHARGE)", "drug_information": { "unit": "30.000000", "type": "UN" }, "code_information": [ { "code": "63323046237_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BUPRENORPHINE 10 MCG/HR TD PTWK", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "42858049340", "type": "NDC" } ], "standard_charges": [ { "minimum": 29.27, "maximum": 97.63, "gross_charge": 103.86, "discounted_cash": 57.12, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.24, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 56.71, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 83.09, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.97, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.22, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.85, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 62.21, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 62.11, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 97.63, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 91.4, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.28, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 77.9, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.59, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 70.62, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 97.63, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 81.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 56.71, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.57, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 77.9, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 91.4, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.24, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 56.71, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BUPRENORPHINE 15 MCG/HR TD PTWK", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "42858058640", "type": "NDC" } ], "standard_charges": [ { "minimum": 54.99, "maximum": 183.42, "gross_charge": 195.13, "discounted_cash": 107.32, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 113.18, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 106.54, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 156.1, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 165.28, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 56.78, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.66, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 116.88, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 116.69, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 183.42, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 171.71, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.99, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 165.86, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 146.35, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 68.74, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 132.69, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 183.42, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 152.79, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 106.54, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 155.13, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 146.35, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 171.71, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 113.18, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 106.54, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BUPRENORPHINE 20 MCG/HR TD PTWK", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "42858083940", "type": "NDC" } ], "standard_charges": [ { "minimum": 76.28, "maximum": 254.44, "gross_charge": 270.68, "discounted_cash": 148.87, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 156.99, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 147.79, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 216.54, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 229.27, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 78.77, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 129.93, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 162.14, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 161.87, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 254.44, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 238.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 76.28, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 230.08, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 203.01, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 95.36, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 184.06, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 254.44, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 211.94, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 147.79, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 215.19, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 203.01, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 238.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 156.99, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 147.79, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BUPRENORPHINE 5 MCG/HR TD PTWK", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00093365640", "type": "NDC" } ], "standard_charges": [ { "minimum": 33.79, "maximum": 112.72, "gross_charge": 119.91, "discounted_cash": 65.95, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 69.55, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.47, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 95.93, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 101.56, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.89, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 57.56, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 71.83, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 71.71, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 112.72, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 105.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.79, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 101.92, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 89.93, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.24, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 81.54, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 112.72, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.89, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.47, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 95.33, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 89.93, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 105.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 69.55, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.47, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BUPRENORPHINE 7.5 MCG/HR TD PTWK", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00093323940", "type": "NDC" } ], "standard_charges": [ { "minimum": 57.55, "maximum": 191.98, "gross_charge": 204.23, "discounted_cash": 112.33, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 118.45, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 111.51, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 163.38, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 172.98, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.43, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 98.03, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 122.33, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 122.13, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 191.98, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 179.72, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 57.55, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 173.6, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 153.17, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 71.95, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 138.88, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 191.98, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 159.91, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 111.51, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 162.36, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 153.17, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 179.72, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 118.45, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 111.51, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BUPRENORPHINE HCL 0.3 MG/ML IJ SOLN", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00409201232", "type": "NDC" } ], "standard_charges": [ { "minimum": 12.68, "maximum": 42.3, "gross_charge": 45.0, "discounted_cash": 24.75, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.1, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.12, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.1, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.91, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.3, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.68, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.25, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.85, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.6, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.3, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.24, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.78, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.1, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BUPRENORPHINE HCL 2 MG SL SUBL", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687048111", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.25, "maximum": 7.52, "gross_charge": 8.0, "discounted_cash": 4.4, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.4, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.78, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.33, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.84, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.79, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.25, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.8, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.82, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.44, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.26, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.36, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BUPRENORPHINE HCL 2 MG SL SUBL (OPIOID WITHDRAWAL)", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687048111_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.25, "maximum": 7.52, "gross_charge": 8.0, "discounted_cash": 4.4, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.4, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.78, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.33, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.84, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.79, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.25, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.8, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.82, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.44, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.26, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.36, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BUPRENORPHINE HCL 8 MG SL SUBL", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687049211", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.25, "maximum": 7.52, "gross_charge": 8.0, "discounted_cash": 4.4, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.4, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.78, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.33, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.84, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.79, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.25, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.8, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.82, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.44, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.26, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.36, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BUPRENORPHINE HCL 8 MG SL SUBL (OPIOID WITHDRAWAL)", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687049211_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.25, "maximum": 7.52, "gross_charge": 8.0, "discounted_cash": 4.4, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.4, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.78, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.33, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.84, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.79, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.25, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.8, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.82, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.44, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.26, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.36, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BUPRENORPHINE HCL-NALOXONE HCL 2-0.5 MG SL SUBL", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00054018813", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.25, "maximum": 7.52, "gross_charge": 8.0, "discounted_cash": 4.4, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.4, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.78, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.33, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.84, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.79, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.25, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.8, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.82, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.44, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.26, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.36, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BUPRENORPHINE HCL-NALOXONE HCL 8-2 MG SL FILM", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "12496120803", "type": "NDC" } ], "standard_charges": [ { "minimum": 5.73, "maximum": 19.11, "gross_charge": 20.33, "discounted_cash": 11.18, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.79, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.1, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.26, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.22, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.92, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.76, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.18, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.16, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.11, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.89, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.73, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.28, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.25, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.16, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.82, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.11, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.92, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.1, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.16, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.25, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.89, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.79, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.1, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BUPRENORPHINE HCL-NALOXONE HCL 8-2 MG SL SUBL", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "62175045832", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.25, "maximum": 7.52, "gross_charge": 8.0, "discounted_cash": 4.4, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.4, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.78, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.33, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.84, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.79, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.25, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.8, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.82, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.44, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.26, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.36, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BUPROPION HCL 100 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687035101", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BUPROPION HCL 75 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687034001", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BUPROPION HCL ER (SR) 100 MG PO TB12", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68084069701", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BUPROPION HCL ER (SR) 150 MG PO TB12", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68084070825", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BUPROPION HCL ER (XL) 150 MG PO TB24", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00904708461", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.18, "maximum": 3.95, "gross_charge": 4.2, "discounted_cash": 2.31, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.44, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.29, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.36, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.56, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.22, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.02, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.52, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.51, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.95, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.7, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.18, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.57, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.15, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.48, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.86, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.95, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.29, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.29, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.34, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.15, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.7, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.44, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.29, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BUPROPION HCL ER (XL) 300 MG PO TB24", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687079321", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BUROSUMAB-TWZA 10 MG/ML SC SOLN", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "42747010201", "type": "NDC" } ], "standard_charges": [ { "minimum": 256.39, "maximum": 12553.09, "gross_charge": 13354.35, "discounted_cash": 7344.89, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 7745.52, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 256.39, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10683.48, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11311.13, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3886.12, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6410.09, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7999.26, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 7985.9, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12553.09, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11751.83, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3763.26, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11351.2, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10015.76, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 4704.74, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 9080.96, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 12553.09, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 10456.46, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": 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}, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21366.98, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 22622.29, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7772.24, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12820.19, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 15998.53, 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"standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 15491.06, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 256.39, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "BUROSUMAB-TWZA 30 MG/ML SC SOLN", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "42747030401", "type": "NDC" } ], "standard_charges": [ { "minimum": 256.39, "maximum": 37659.3, "gross_charge": 40063.08, "discounted_cash": 22034.69, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", 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charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11289.78, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34053.62, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30047.31, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14114.22, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": 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"plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30047.31, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35255.51, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23236.59, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 256.39, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "BUSPIRONE HCL 10 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "51079098620", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BUSPIRONE HCL 15 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687082301", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BUSPIRONE HCL 5 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "51079098520", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BUSULFAN 6 MG/ML IV SOLN", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "71288011611", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.69, "maximum": 69.39, "gross_charge": 73.82, "discounted_cash": 40.6, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.82, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.69, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.06, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 62.53, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.48, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.43, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 44.22, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 44.14, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 69.39, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 64.96, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.8, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 62.75, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.37, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.01, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 69.39, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 57.8, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.94, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 58.69, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.37, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 64.96, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.82, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.69, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "BUTAMBEN-TETRACAINE-BENZOCAINE 2-2-14 % EX AERO", "drug_information": { "unit": "20.000000", "type": "GR" }, "code_information": [ { "code": "10223020103", "type": "NDC" } ], "standard_charges": [ { "minimum": 85.17, "maximum": 284.12, "gross_charge": 302.25, "discounted_cash": 166.24, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 175.31, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 165.03, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 241.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 256.01, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.95, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 145.08, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 181.05, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 180.75, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 284.12, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 265.98, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 85.17, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 256.91, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 226.69, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 106.48, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 205.53, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 284.12, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 236.66, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 165.03, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 240.29, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 226.69, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 265.98, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 175.31, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 165.03, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BUTORPHANOL TARTRATE 10 MG/ML NA SOLN", "drug_information": { "unit": "2.500000", "type": "UN" }, "code_information": [ { "code": "60505081301", "type": "NDC" } ], "standard_charges": [ { "minimum": 35.99, "maximum": 120.07, "gross_charge": 127.73, "discounted_cash": 70.25, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.08, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 69.74, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 102.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 108.19, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.17, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.31, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 76.51, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 76.38, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 120.07, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 112.4, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.99, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 108.57, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 95.8, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.0, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.86, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 120.07, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 100.01, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 69.74, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 101.55, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 95.8, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 112.4, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.08, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 69.74, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BUTORPHANOL TARTRATE 2 MG/ML IJ SOLN", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00409162601", "type": "NDC" } ], "standard_charges": [ { "minimum": 12.68, "maximum": 42.3, "gross_charge": 45.0, "discounted_cash": 24.75, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.1, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.12, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.1, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.91, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.3, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.68, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.25, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.85, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.6, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.3, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.24, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.78, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.1, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "BUTT BALM OINTMENT WITH CHOLESTYRAMINE 10%", "drug_information": { "unit": "50.000000", "type": "GR" }, "code_information": [ { "code": "P8252100050", "type": "NDC" } ], "standard_charges": [ { "minimum": 10.0, "maximum": 1158.0, "gross_charge": 35.47, "discounted_cash": 19.51, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.57, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.79, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.32, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.03, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.25, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.21, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.34, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.21, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.15, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.6, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.5, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.12, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.34, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.77, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.6, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.21, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.57, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Bx breast 1st lesion mr imag", "code_information": [ { "code": "19085", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1194.28, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 884.65, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 3764.64, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 6831.01, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1194.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 6831.01, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Bx breast 1st lesion strtctc", "code_information": [ { "code": "19081", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1194.28, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 884.65, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 3625.76, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 6579.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1194.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 6579.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Bx breast 1st lesion us imag", "code_information": [ { "code": "19083", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1194.28, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 884.65, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 3576.16, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 6489.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1194.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 6489.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Bx breast percut w/o image", "code_information": [ { "code": "19100", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1194.28, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 884.65, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 8446.88, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 15327.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1194.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 15327.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Bx of cervix w/scope leep", "code_information": [ { "code": "57460", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2343.63, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1736.02, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 7650.21, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 13888.63, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2343.63, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 13888.63, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Bx/curett of cervix w/scope", "code_information": [ { "code": "57454", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 224.22, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 1902.65, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 3456.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 224.22, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 3456.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Bx/exc xdrl spine lesn lmbr", "code_information": [ { "code": "63277", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 21820.29, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 39593.27, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 39593.27, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "C-laminoplasty w/graft/plate", "code_information": [ { "code": "63051", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 48218.4, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 87493.1, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 87493.1, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "C1 ESTERASE INHIBITOR (HUMAN) 500 UNITS IV KIT", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "63833082502", "type": "NDC" } ], "standard_charges": [ { "minimum": 2940.39, "maximum": 9808.27, "gross_charge": 10434.33, "discounted_cash": 5738.88, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 6051.91, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5697.14, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8347.46, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8837.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3036.39, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5008.48, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6250.16, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 6239.73, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9808.27, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9182.21, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2940.39, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8869.18, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7825.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3676.01, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7095.34, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 9808.27, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8170.08, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5697.14, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 8295.29, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7825.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9182.21, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6051.91, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5697.14, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Ca screen;flexi sigmoidscope", "code_information": [ { "code": "G0104", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 672.02, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 497.79, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 2470.08, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 4482.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 672.02, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 4482.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CABAZITAXEL 60 MG/1.5ML IV SOLN", "drug_information": { "unit": "6.000000", "type": "UN" }, "code_information": [ { "code": "00024582411", "type": "NDC" } ], "standard_charges": [ { "minimum": 11394.0, "maximum": 39893.21, "gross_charge": 42439.59, "discounted_cash": 23341.77, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 24614.96, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23172.02, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33951.67, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35946.33, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12349.92, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20371.0, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 25421.31, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 11394.0, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39893.21, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37346.84, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11959.48, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 36073.65, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 31829.69, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14951.47, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 28858.92, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 39893.21, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 33230.2, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23172.02, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 15189.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 31829.69, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37346.84, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24614.96, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23172.02, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CABERGOLINE 0.5 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "2315582373", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.76, "maximum": 9.21, "gross_charge": 9.8, "discounted_cash": 5.39, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.68, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.35, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.84, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.3, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.85, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.7, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.87, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.86, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.21, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.62, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.76, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.33, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.35, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.45, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.66, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.21, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.67, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.35, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.79, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.35, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.62, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.68, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.35, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CADEXOMER IODINE 0.9 % EX GEL", "drug_information": { "unit": "40.000000", "type": "GR" }, "code_information": [ { "code": "40565012249", "type": "NDC" } ], "standard_charges": [ { "minimum": 63.11, "maximum": 210.51, "gross_charge": 223.95, "discounted_cash": 123.17, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 129.89, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 122.28, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 179.16, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 189.69, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.17, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 107.5, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 134.15, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 133.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 210.51, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 197.08, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.11, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 190.36, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 167.96, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 78.9, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 152.29, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 210.51, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 175.35, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 122.28, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 178.04, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 167.96, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 197.08, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 129.89, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 122.28, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CAFFEINE 200 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "46122045773", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CAFFEINE CITRATE 60 MG/3ML (IV FOR PO)", "drug_information": { "unit": "3.000000", "type": "UN" }, "code_information": [ { "code": "25021060103", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.79, "maximum": 9.31, "gross_charge": 9.9, "discounted_cash": 5.45, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.74, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.41, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.92, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.88, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.75, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.93, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.31, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.71, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.79, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.42, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.43, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.49, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.73, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.31, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.75, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.41, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.87, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.43, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.71, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.74, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.41, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CAFFEINE CITRATE 60 MG/3ML IV SOLN", "drug_information": { "unit": "3.000000", "type": "UN" }, "code_information": [ { "code": "25021060103_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CAFFEINE-SODIUM BENZOATE 125-125 MG/ML IJ SOLN", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00517250210", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 1158.0, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.72, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CALAMINE-ZINC OXIDE 8-8 % EX LOTN", "drug_information": { "unit": "177.000000", "type": "UN" }, "code_information": [ { "code": "00904253321", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed 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"standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", 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"Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CALASPARGASE PEGOL-MKNL 3750 UNIT/5ML IV SOLN", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "72694051501", "type": "NDC" } ], "standard_charges": [ { "minimum": 11394.0, "maximum": 70593.4, "gross_charge": 75099.36, "discounted_cash": 41304.65, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 43557.63, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 41004.25, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 60079.49, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 63609.16, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21853.91, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 36047.69, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 44984.52, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 11394.0, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 70593.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 66087.44, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 21163.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 63834.46, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 56324.52, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 26457.5, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 51067.56, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 70593.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 58802.8, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 41004.25, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 15189.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 56324.52, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 66087.44, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 43557.63, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 41004.25, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CALCITONIN (SALMON) 200 UNIT/ACT NA SOLN", "drug_information": { "unit": "3.700000", "type": "UN" }, "code_information": [ { "code": "60505082306", "type": "NDC" } ], "standard_charges": [ { "minimum": 41.06, "maximum": 136.96, "gross_charge": 145.7, "discounted_cash": 80.14, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 84.51, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 79.55, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 116.56, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 123.41, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.4, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 69.94, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.27, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.13, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 136.96, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 128.22, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.06, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 123.85, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 109.28, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 51.33, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 99.08, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 136.96, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 114.08, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 79.55, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 115.83, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 109.28, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 128.22, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 84.51, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 79.55, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CALCITONIN (SALMON) 200 UNIT/ML IJ SOLN", "drug_information": { "unit": "2.000000", "type": "UN" }, "code_information": [ { "code": "42023020501", "type": "NDC" } ], "standard_charges": [ { "minimum": 640.49, "maximum": 2605.15, "gross_charge": 2771.44, "discounted_cash": 1524.29, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1607.44, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 640.49, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2217.15, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2347.41, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 806.49, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1330.29, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1660.09, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 1657.32, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2605.15, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2438.87, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 780.99, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2355.72, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2078.58, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 976.38, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1884.58, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2605.15, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2170.04, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 864.66, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2203.29, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2078.58, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2438.87, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1607.44, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 640.49, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "CALCITRIOL 0.25 MCG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687034501", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CALCITRIOL 0.5 MCG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "R6945220820", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CALCITRIOL 1 MCG/ML PO SOLN", "drug_information": { "unit": "0.250000", "type": "UN" }, "code_information": [ { "code": "64980044715", "type": "NDC" } ], "standard_charges": [ { "minimum": 4.26, "maximum": 14.19, "gross_charge": 15.1, "discounted_cash": 8.31, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.76, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.24, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.08, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.79, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.39, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.25, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.04, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.03, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.19, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.29, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.26, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.84, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.33, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.32, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.27, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.19, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.82, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.24, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.33, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.29, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.76, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.24, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CALCIUM ACETATE (PHOS BINDER) 667 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68084047901", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CALCIUM CARB-CHOLECALCIFEROL 250-3.125 MG-MCG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "20555002500", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CALCIUM CARBONATE 1500 (600 CA) MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "80681000500", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CALCIUM CARBONATE ANTACID 500 (200 CA) MG PO CHEW", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68084098832", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CALCIUM CHLORIDE 10 % IV SOLN", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "00517671010", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 1158.0, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.72, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CALCIUM CHLORIDE 10 % IV SOLN -CODE USE PEDS", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "76329330401", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 1158.0, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.72, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CALCIUM CHLORIDE 10 % IV SOLN 10 ML SYRINGE (BULK CHARGE)", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "76329330401_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 1158.0, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.72, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CALCIUM CHLORIDE 10 % IV SOLN 10 ML VIAL (BULK CHARGE)", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "00517671010_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 1158.0, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.72, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CALCIUM CHLORIDE 10 % IV SOLN EXCHANGE TRANSFUSION (NICU)", "drug_information": { "unit": "0.330000", "type": "UN" }, "code_information": [ { "code": "00517671010_3", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 1158.0, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.72, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CALCIUM CHLORIDE 10% IV SOLN FOR PCTU", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "00517671010_4", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 1158.0, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.72, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CALCIUM CHLORIDE IVPB (APHERESIS)", "drug_information": { "unit": "100.000000", "type": "UN" }, "code_information": [ { "code": "08252000179", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CALCIUM CHLORIDE IVPB (APHERESIS) PRN", "drug_information": { "unit": "100.000000", "type": "UN" }, "code_information": [ { "code": "08252000179_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CALCIUM CITRATE 950 (200 CA) MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "80681014000", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CALCIUM GLUCONATE (ANTIDOTE) 2.5 % EX GEL", "drug_information": { "unit": "25.000000", "type": "GR" }, "code_information": [ { "code": "35181730332", "type": "NDC" } ], "standard_charges": [ { "minimum": 22.64, "maximum": 75.51, "gross_charge": 80.33, "discounted_cash": 44.18, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.59, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.86, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 64.26, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 68.04, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.38, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.56, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 48.12, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 48.04, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.51, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 70.69, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.64, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 68.28, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.25, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.3, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.62, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.51, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 62.9, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.86, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.86, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.25, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 70.69, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.59, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.86, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CALCIUM GLUCONATE 10 % IV SOLN", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "63323036019_5", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CALCIUM GLUCONATE 10 % IV SOLN (APHERESIS)", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "63323036019_6", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CALCIUM GLUCONATE 10 % IV SOLN (NICU)", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "63323036019_7", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CALCIUM GLUCONATE 10 % IV SOLN (NICU)|DISCARDED DRUG NOT ADMINISTERED", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "63323036019", "type": "NDC" } ], "standard_charges": [ { "minimum": 5.1, "maximum": 17.0, "gross_charge": 18.09, "discounted_cash": 9.95, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.49, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.88, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.47, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.32, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.26, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.68, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.84, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.82, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.92, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.1, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.38, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.57, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.37, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.3, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.16, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.88, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.38, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.57, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.92, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.49, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.88, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CALCIUM GLUCONATE 10 % IV SOLN 10 ML VIAL (BULK CHARGE)", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "63323036019_8", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CALCIUM GLUCONATE 10 % IV SOLN 10 ML VIAL (BULK CHARGE)|DISCARDED DRUG NOT ADMINISTERED", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "63323036019_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 5.1, "maximum": 17.0, "gross_charge": 18.09, "discounted_cash": 9.95, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.49, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.88, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.47, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.32, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.26, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.68, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.84, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.82, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.92, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.1, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.38, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.57, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.37, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.3, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.16, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.88, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.38, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.57, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.92, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.49, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.88, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CALCIUM GLUCONATE 10 % IV SOLN FOR HYPERKALEMIA", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "63323036019_9", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CALCIUM GLUCONATE 10 % IV SOLN FOR HYPERKALEMIA|DISCARDED DRUG NOT ADMINISTERED", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "63323036019_3", "type": "NDC" } ], "standard_charges": [ { "minimum": 5.1, "maximum": 17.0, "gross_charge": 18.09, "discounted_cash": 9.95, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.49, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.88, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.47, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.32, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.26, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.68, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.84, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.82, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.92, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.1, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.38, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.57, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.37, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.3, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.16, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.88, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.38, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.57, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.92, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.49, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.88, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CALCIUM GLUCONATE 10% DRIP (PEDS)", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "63323036019_10", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CALCIUM GLUCONATE 10% DRIP (PEDS)|DISCARDED DRUG NOT ADMINISTERED", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "63323036019_4", "type": "NDC" } ], "standard_charges": [ { "minimum": 5.1, "maximum": 17.0, "gross_charge": 18.09, "discounted_cash": 9.95, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.49, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.88, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.47, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.32, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.26, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.68, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.84, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.82, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.92, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.1, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.38, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.57, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.37, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.3, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.16, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.88, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.38, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.57, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.92, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.49, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.88, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CALCIUM GLUCONATE 20 MG/ML PERIPHERAL (PICU/NICU) IV SYRINGE FROM RTU", "drug_information": { "unit": "50.000000", "type": "UN" }, "code_information": [ { "code": "44567062024_4", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CALCIUM GLUCONATE 20 MG/ML PERIPHERAL (PICU/NICU) IV SYRINGE FROM RTU|DISCARDED DRUG NOT ADMINISTERED", "drug_information": { "unit": "50.000000", "type": "UN" }, "code_information": [ { "code": "44567062024_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 5.46, "maximum": 18.2, "gross_charge": 19.36, "discounted_cash": 10.65, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.23, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.49, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.63, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.29, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.6, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.58, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.2, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.46, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.46, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.52, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.82, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.16, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.2, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.16, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.39, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.52, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.23, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CALCIUM GLUCONATE 20 MG/ML PERIPHERAL (PICU/NICU) IVPB FROM RTU", "drug_information": { "unit": "50.000000", "type": "UN" }, "code_information": [ { "code": "44567062024_3", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 1158.0, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 95.48, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CALCIUM GLUCONATE 20 MG/ML PERIPHERAL (PICU/NICU) IVPB FROM RTU|DISCARDED DRUG NOT ADMINISTERED", "drug_information": { "unit": "50.000000", "type": "UN" }, "code_information": [ { "code": "44567062024", "type": "NDC" } ], "standard_charges": [ { "minimum": 5.46, "maximum": 1158.0, "gross_charge": 19.36, "discounted_cash": 10.65, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.23, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.8, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.63, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.29, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.6, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.58, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.2, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.46, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.46, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.52, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.82, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.16, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.2, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.16, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.39, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.52, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.23, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CALCIUM GLUCONATE IVPB (APHERESIS)", "drug_information": { "unit": "25.000000", "type": "UN" }, "code_information": [ { "code": "08252000073", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CALCIUM GLUCONATE IVPB RTU (APHERESIS)", "drug_information": { "unit": "25.000000", "type": "UN" }, "code_information": [ { "code": "44567062024_5", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CALCIUM GLUCONATE-NACL 1-0.675 GM/50ML-% IV SOLN", "drug_information": { "unit": "50.000000", "type": "UN" }, "code_information": [ { "code": "44567062024_6", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CALCIUM POLYCARBOPHIL 625 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00536430608", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CANAKINUMAB 150 MG/ML SC SOLN", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00078073461", "type": "NDC" } ], "standard_charges": [ { "minimum": 69.78, "maximum": 54831.69, "gross_charge": 58331.58, "discounted_cash": 32082.37, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 33832.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 69.78, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 46665.26, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 49406.85, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16974.49, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 27999.16, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 34940.62, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 11394.0, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 54831.69, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 51331.79, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 16437.84, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 49581.84, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 43748.69, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 20550.22, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 39665.47, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 54831.69, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 45673.63, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 94.21, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 15189.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 43748.69, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 51331.79, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 33832.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 69.78, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "CANDESARTAN CILEXETIL 16 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687024125", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.2, "maximum": 7.32, "gross_charge": 7.79, "discounted_cash": 4.28, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.52, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.25, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.23, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.6, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.27, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.74, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.67, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.66, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.32, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.86, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.2, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.62, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.84, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.74, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.3, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.32, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.1, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.25, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.19, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.84, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.86, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.52, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.25, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CANDESARTAN CILEXETIL 32 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687013025", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.83, "maximum": 9.44, "gross_charge": 10.04, "discounted_cash": 5.52, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.82, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.48, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.03, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.92, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.82, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.01, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.44, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.84, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.83, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.53, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.53, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.54, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.83, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.44, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.86, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.48, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.98, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.53, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.84, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.82, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.48, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CANDESARTAN CILEXETIL 4 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "33342011407", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CANDIDA ALBICANS SKN TST ANTGN ID SOLN", "drug_information": { "unit": "0.100000", "type": "UN" }, "code_information": [ { "code": "59584013801", "type": "NDC" } ], "standard_charges": [ { "minimum": 18.89, "maximum": 1158.0, "gross_charge": 67.02, "discounted_cash": 36.86, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.87, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.59, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 58.17, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.5, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.17, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.14, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.08, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 58.98, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.89, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 56.97, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.27, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.61, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.57, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.48, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.59, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 53.28, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.27, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 58.98, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.87, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.59, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CANGRELOR TETRASODIUM 50 MG IV SOLR", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "10122062010", "type": "NDC" } ], "standard_charges": [ { "minimum": 972.34, "maximum": 3243.44, "gross_charge": 3450.47, "discounted_cash": 1897.76, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2001.27, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1883.96, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2760.38, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2922.55, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1004.09, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1656.23, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2066.83, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2063.38, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3243.44, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3036.41, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 972.34, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2932.9, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2587.85, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1215.6, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2346.32, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3243.44, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2701.72, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1883.96, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2743.12, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2587.85, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3036.41, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2001.27, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1883.96, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CANNABIDIOL 100 MG/ML PO SOLN", "drug_information": { "unit": "60.000000", "type": "UN" }, "code_information": [ { "code": "70127010060", "type": "NDC" } ], "standard_charges": [ { "minimum": 691.11, "maximum": 2305.35, "gross_charge": 2452.5, "discounted_cash": 1348.88, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1422.45, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1339.07, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1962.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2077.27, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 713.68, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1177.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1469.05, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 1466.6, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2305.35, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2158.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 691.11, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2084.63, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1839.38, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 864.02, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1667.7, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2305.35, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1920.31, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1339.07, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1949.74, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1839.38, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2158.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1422.45, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1339.07, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Cannula declotting", "code_information": [ { "code": "36861", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 3984.54, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2951.51, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 15144.51, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 27479.96, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3984.54, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 27479.96, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CAPECITABINE 150 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "55111049660_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CAPECITABINE 150 MG PO TABS|DISCARDED DRUG NOT ADMINISTERED", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "55111049660", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.15, "maximum": 0.51, "gross_charge": 0.54, "discounted_cash": 0.3, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.31, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.29, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.43, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.46, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.26, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.32, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.32, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.51, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.15, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.46, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.41, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.19, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.37, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.51, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.42, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.29, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.43, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.41, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.31, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.29, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CAPECITABINE 500 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687014994", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.03, "maximum": 4.34, "gross_charge": 4.62, "discounted_cash": 2.54, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.68, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.03, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.7, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.91, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.34, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.22, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.77, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.76, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.34, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.07, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.3, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.93, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.47, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.63, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.14, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.34, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.62, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.04, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.67, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.47, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.07, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.68, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.03, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "CAPSAICIN 0.025 % EX CREA", "drug_information": { "unit": "60.000000", "type": "GR" }, "code_information": [ { "code": "00536252525", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.0, "maximum": 6.66, "gross_charge": 7.08, "discounted_cash": 3.89, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.11, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.87, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.66, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.06, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.24, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.23, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.66, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.23, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.02, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.31, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.49, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.81, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.66, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.54, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.87, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.63, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.31, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.23, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.11, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.87, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CAPSAICIN 0.075 % EX CREA", "drug_information": { "unit": "57.000000", "type": "GR" }, "code_information": [ { "code": "00536111825", "type": "NDC" } ], "standard_charges": [ { "minimum": 3.0, "maximum": 9.99, "gross_charge": 10.63, "discounted_cash": 5.85, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.17, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.8, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.5, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.09, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.1, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.37, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.36, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.99, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.35, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.04, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.97, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.74, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.23, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.99, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.8, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.97, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.35, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.17, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.8, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CAPTOPRIL 1 MG/ML ORAL SUSPENSION", "drug_information": { "unit": "100.000000", "type": "UN" }, "code_information": [ { "code": "P0143117401", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.34, "maximum": 4.47, "gross_charge": 4.75, "discounted_cash": 2.61, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.76, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.59, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.02, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.38, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.28, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.85, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.84, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.47, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.18, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.34, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.04, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.56, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.67, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.23, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.47, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.72, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.59, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.78, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.56, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.18, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.76, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.59, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CAPTOPRIL 100 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "R6929252801", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CAPTOPRIL 12.5 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687030421", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CAPTOPRIL 25 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687031521", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CAPTOPRIL 50 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "R6929252601", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.18, "maximum": 3.95, "gross_charge": 4.2, "discounted_cash": 2.31, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.44, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.29, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.36, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.56, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.22, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.02, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.52, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.51, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.95, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.7, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.18, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.57, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.15, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.48, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.86, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.95, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.29, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.29, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.34, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.15, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.7, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.44, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.29, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CAPTOPRIL 6.25 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "R0143117101", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CARBACHOL 0.01 % IO SOLN", "drug_information": { "unit": "0.500000", "type": "UN" }, "code_information": [ { "code": "00065002315", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 1158.0, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.72, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CARBAMAZEPINE 100 MG PO CHEW", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687047901", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CARBAMAZEPINE 100 MG/5ML PO SUSP", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "17856404701", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.74, "maximum": 9.14, "gross_charge": 9.72, "discounted_cash": 5.35, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.31, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.78, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.23, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.83, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.67, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.82, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.81, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.14, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.55, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.74, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.26, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.29, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.42, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.61, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.14, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.61, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.31, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.73, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.29, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.55, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.31, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CARBAMAZEPINE 200 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68084044401", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CARBAMAZEPINE ER 100 MG PO CP12", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "66993040732", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CARBAMAZEPINE ER 100 MG PO TB12", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00832602211", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CARBAMAZEPINE ER 200 MG PO CP12", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "66993040832", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CARBAMAZEPINE ER 200 MG PO TB12", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687058321", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.65, "maximum": 5.5, "gross_charge": 5.85, "discounted_cash": 3.22, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.19, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.68, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.95, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.7, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.81, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.5, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.5, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.5, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.15, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.65, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.97, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.39, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.06, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.98, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.5, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.58, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.19, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.65, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.39, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.15, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.19, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CARBAMAZEPINE ER 300 MG PO CP12", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "66993040932", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CARBAMAZEPINE ER 400 MG PO TB12", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687059421", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.84, "maximum": 9.48, "gross_charge": 10.09, "discounted_cash": 5.55, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.85, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.51, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.07, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.55, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.94, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.84, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.04, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.03, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.48, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.88, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.84, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.58, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.57, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.55, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.86, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.48, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.9, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.51, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.02, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.57, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.88, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.85, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.51, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CARBAMIDE PEROXIDE 6.5 % OT SOLN", "drug_information": { "unit": "15.000000", "type": "UN" }, "code_information": [ { "code": "46122055705", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CARBIDOPA 25 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "R4279912301", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.26, "maximum": 7.55, "gross_charge": 8.03, "discounted_cash": 4.42, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.66, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.38, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.42, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.8, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.34, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.85, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.81, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.8, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.55, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.07, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.26, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.83, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.02, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.83, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.46, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.55, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.29, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.38, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.38, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.02, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.07, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.66, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.38, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CARBIDOPA-LEVODOPA 10-100 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "3535662860", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CARBIDOPA-LEVODOPA 10-100 MG PO TBDP", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "47335018688", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CARBIDOPA-LEVODOPA 25-100 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "4229146601", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", 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"additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CARBIDOPA-LEVODOPA 25-100 MG PO TBDP", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "47335018788", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CARBIDOPA-LEVODOPA ER 23.75-95 MG PO CPCR", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "64896066101", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.65, "maximum": 8.85, "gross_charge": 9.41, "discounted_cash": 5.18, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.46, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.14, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.53, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.97, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.74, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.52, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.64, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.63, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.85, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.28, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.65, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.06, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.32, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.4, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.85, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.37, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.14, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.48, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.06, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.28, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.46, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.14, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CARBIDOPA-LEVODOPA ER 25-100 MG PO TBCR", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68084028101", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CARBIDOPA-LEVODOPA ER 36.25-145 MG PO CPCR", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "64896066201", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.65, "maximum": 8.85, "gross_charge": 9.41, "discounted_cash": 5.18, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.46, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.14, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.53, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.97, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.74, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.52, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.64, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.63, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.85, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.28, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.65, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.06, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.32, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.4, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.85, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.37, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.14, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.48, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.06, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.28, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.46, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.14, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CARBIDOPA-LEVODOPA ER 48.75-195 MG PO CPCR", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "64896066301", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.65, "maximum": 8.85, "gross_charge": 9.41, "discounted_cash": 5.18, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.46, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.14, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.53, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.97, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.74, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.52, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.64, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.63, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.85, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.28, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.65, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.06, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.32, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.4, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.85, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.37, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.14, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.48, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.06, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.28, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.46, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.14, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CARBIDOPA-LEVODOPA ER 50-200 MG PO TBCR", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68084028201", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CARBIDOPA-LEVODOPA ER 61.25-245 MG PO CPCR", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "64896066401", "type": "NDC" } ], "standard_charges": [ { "minimum": 3.33, "maximum": 11.11, "gross_charge": 11.82, "discounted_cash": 6.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.86, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.45, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.46, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.01, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.44, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.67, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.08, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.07, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.11, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.4, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.33, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.05, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.87, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.16, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.04, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.11, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.26, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.45, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.4, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.87, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.4, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.86, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.45, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CARBONYL IRON 45 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "46017009660", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CARBOPLATIN 150 MG/15ML IV SOLN", "drug_information": { "unit": "15.000000", "type": "UN" }, "code_information": [ { "code": "00703424601", "type": "NDC" } ], "standard_charges": [ { "minimum": 13.0, "maximum": 43.36, "gross_charge": 46.13, "discounted_cash": 25.37, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.76, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.19, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.9, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.07, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.42, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.14, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.63, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.59, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.36, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.59, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.21, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.6, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.25, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.37, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.36, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.12, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.19, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.67, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.6, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.59, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.76, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.19, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CARBOPLATIN 50 MG/5ML IV SOLN", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "00703424401", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CARBOPLATIN 600 MG/60ML IV SOLN", "drug_information": { "unit": "60.000000", "type": "UN" }, "code_information": [ { "code": "61703033956", "type": "NDC" } ], "standard_charges": [ { "minimum": 16.75, "maximum": 55.88, "gross_charge": 59.45, "discounted_cash": 32.7, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.48, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.46, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.56, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.35, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.3, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.54, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.61, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.55, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.88, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.32, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.75, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.53, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 44.59, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.94, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.43, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.88, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.55, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.46, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.26, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 44.59, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.32, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.48, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.46, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CARBOPROST TROMETHAMINE 250 MCG/ML IM SOLN", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "81298501003", "type": "NDC" } ], "standard_charges": [ { "minimum": 33.82, "maximum": 1158.0, "gross_charge": 120.01, "discounted_cash": 66.01, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 69.61, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.53, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 104.17, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.92, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 57.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 71.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 71.77, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 112.81, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 105.61, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.82, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 102.01, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 90.01, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.28, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 81.61, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 112.81, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.97, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.53, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 95.41, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 90.01, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 105.61, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 69.61, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.53, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CARBOXYMETHYLCELLULOSE SOD PF 0.5 % OP SOLN", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "C0536138792", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CARBOXYMETHYLCELLULOSE SOD PF 1 % OP GEL", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00023455430", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CARDIOPLEGIA 4:1 LOW K BAG", "drug_information": { "unit": "810.000000", "type": "UN" }, "code_information": [ { "code": "66647011003", "type": "NDC" } ], "standard_charges": [ { "minimum": 49.32, "maximum": 164.5, "gross_charge": 175.0, "discounted_cash": 96.25, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 101.5, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 95.55, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 140.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 148.23, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.93, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 84.0, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 104.83, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 104.65, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 164.5, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 154.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.32, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 148.75, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 131.25, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.65, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 119.0, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 164.5, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 137.03, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 95.55, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 139.13, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 131.25, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 154.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 101.5, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 95.55, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CARDIOPLEGIA NO K BAG", "drug_information": { "unit": "477.500000", "type": "UN" }, "code_information": [ { "code": "66647010006", "type": "NDC" } ], "standard_charges": [ { "minimum": 42.55, "maximum": 141.94, "gross_charge": 151.0, "discounted_cash": 83.05, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.58, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.45, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 120.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 127.9, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.94, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 72.48, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 90.45, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 90.3, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 141.94, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 132.88, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.55, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 128.35, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 113.25, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 53.2, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 102.68, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 141.94, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 118.23, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.45, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 120.05, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 113.25, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 132.88, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.58, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.45, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CARDIOPLEGIA SOLUTION A 1000 ML BAG", "drug_information": { "unit": "1000.000000", "type": "UN" }, "code_information": [ { "code": "P8252000110", "type": "NDC" } ], "standard_charges": [ { "minimum": 28.18, "maximum": 1158.0, "gross_charge": 100.0, "discounted_cash": 55.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 58.0, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.6, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.8, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.1, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 48.0, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.9, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.8, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 94.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.18, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 85.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.23, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 68.0, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 94.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 78.3, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.6, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 79.5, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 58.0, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.6, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CARDIOPLEGIA SOLUTION R (DEL NIDO FORMULA)", "drug_information": { "unit": "1052.800000", "type": "UN" }, "code_information": [ { "code": "66647012002", "type": "NDC" } ], "standard_charges": [ { "minimum": 28.18, "maximum": 1158.0, "gross_charge": 100.0, "discounted_cash": 55.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 58.0, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.6, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.8, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.1, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 48.0, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.9, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.8, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 94.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.18, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 85.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.23, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 68.0, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 94.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 78.3, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.6, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 79.5, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 58.0, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.6, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Cardioversion electric ext", "code_information": [ { "code": "92960", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 482.34, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 357.29, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 5087.47, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 9231.3, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 482.34, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 9231.3, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Care of miscarriage", "code_information": [ { "code": "59820", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2343.63, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1736.02, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 5899.43, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 10704.6, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2343.63, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 10704.6, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CARFILZOMIB 30 MG IV SOLR", "drug_information": { "unit": "15.000000", "type": "UN" }, "code_information": [ { "code": "76075010201", "type": "NDC" } ], "standard_charges": [ { "minimum": 27.07, "maximum": 4618.0, "gross_charge": 4912.77, "discounted_cash": 2702.02, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2849.41, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.07, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3930.22, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4161.12, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1429.62, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2358.13, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2942.75, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2937.84, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4618.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4323.24, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1384.42, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4175.85, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3684.58, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1730.77, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3340.68, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4618.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3846.7, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.55, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3905.65, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3684.58, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4323.24, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2849.41, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.07, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "CARGLUMIC ACID 200 MG PO TBSO", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "52276031205", "type": "NDC" } ], "standard_charges": [ { "minimum": 207.17, "maximum": 691.07, "gross_charge": 735.18, "discounted_cash": 404.35, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 426.4, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 401.41, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 588.14, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 622.7, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 213.94, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 352.89, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 440.37, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 439.64, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 691.07, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 646.96, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 207.17, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 624.9, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 551.39, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 259.0, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 499.92, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 691.07, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 575.65, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 401.41, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 584.47, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 551.39, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 646.96, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 426.4, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 401.41, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CARIPRAZINE HCL 1.5 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "61874011520", "type": "NDC" } ], "standard_charges": [ { "minimum": 30.75, "maximum": 102.58, "gross_charge": 109.13, "discounted_cash": 60.02, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.3, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.58, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.3, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 92.43, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.76, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.38, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.37, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.26, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 102.58, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.03, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.75, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 92.76, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 81.85, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.45, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.21, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 102.58, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 85.45, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.58, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.76, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 81.85, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.03, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.3, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.58, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CARIPRAZINE HCL 3 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "61874013020", "type": "NDC" } ], "standard_charges": [ { "minimum": 30.75, "maximum": 102.58, "gross_charge": 109.13, "discounted_cash": 60.02, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.3, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.58, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.3, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 92.43, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.76, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.38, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.37, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.26, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 102.58, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.03, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.75, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 92.76, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 81.85, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.45, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.21, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 102.58, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 85.45, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.58, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.76, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 81.85, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.03, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.3, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.58, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CARIPRAZINE HCL 6 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "61874016030", "type": "NDC" } ], "standard_charges": [ { "minimum": 30.75, "maximum": 102.58, "gross_charge": 109.13, "discounted_cash": 60.02, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.3, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.58, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.3, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 92.43, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.76, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.38, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.37, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.26, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 102.58, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.03, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.75, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 92.76, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 81.85, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.45, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.21, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 102.58, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 85.45, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.58, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.76, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 81.85, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.03, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.3, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.58, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CARISOPRODOL 250 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00037225030", "type": "NDC" } ], "standard_charges": [ { "minimum": 4.68, "maximum": 15.59, "gross_charge": 16.59, "discounted_cash": 9.12, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.62, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.27, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.05, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.83, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.96, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.94, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.59, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.68, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.1, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.44, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.84, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.28, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.59, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.99, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.19, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.44, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.62, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CARISOPRODOL 350 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "1263443712", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.25, "maximum": 7.52, "gross_charge": 8.0, "discounted_cash": 4.4, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.4, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.78, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.33, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.84, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.79, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.25, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.8, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.82, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.44, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.26, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.36, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CARMUSTINE 100 MG IV SOLR", "drug_information": { "unit": "30.000000", "type": "UN" }, "code_information": [ { "code": "23155064941", "type": "NDC" } ], "standard_charges": [ { "minimum": 173.3, "maximum": 578.09, "gross_charge": 614.99, "discounted_cash": 338.24, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 356.69, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 180.66, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 491.99, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 520.9, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 178.96, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 295.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 368.38, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 367.76, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 578.09, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 541.19, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 173.3, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 522.74, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 461.24, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 216.66, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 418.19, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 578.09, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 481.54, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 243.88, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 488.92, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 461.24, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 541.19, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 356.69, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 180.66, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "CARMUSTINE IN POLIFEPROSAN 7.7 MG IL WAFR", "drug_information": { "unit": "62.000000", "type": "ME" }, "code_information": [ { "code": "24338005008", "type": "NDC" } ], "standard_charges": [ { "minimum": 11394.0, "maximum": 109991.01, "gross_charge": 117011.71, "discounted_cash": 64356.44, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 67866.79, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63888.39, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93609.37, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 99108.92, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34050.41, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 56165.62, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 70090.01, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 11394.0, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 109991.01, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 102970.3, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 32973.9, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 99459.95, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 87758.78, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 41223.23, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 79567.96, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 109991.01, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 91620.17, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63888.39, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 15189.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 87758.78, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 102970.3, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 67866.79, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63888.39, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Carpal tunnel surgery", "code_information": [ { "code": "64721", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1439.39, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1066.21, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 6037.3, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 10954.8, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1439.39, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 10954.8, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CARVEDILOL 0.5 MG/ML ORAL SUSPENSION", "drug_information": { "unit": "6.300000", "type": "UN" }, "code_information": [ { "code": "P0093005100", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CARVEDILOL 12.5 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00904730761", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": 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"percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", 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"additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CARVEDILOL 25 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "1013563701", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CARVEDILOL 6.25 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68084085401", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CARVEDILOL PHOSPHATE ER 10 MG PO CP24", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "57664066383", "type": "NDC" } ], "standard_charges": [ { "minimum": 3.68, "maximum": 12.27, "gross_charge": 13.05, "discounted_cash": 7.18, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.57, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.13, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.44, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.05, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.8, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.26, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.82, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.8, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.27, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.48, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.68, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.09, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.79, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.6, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.87, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.27, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.22, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.13, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.37, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.79, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.48, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.57, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.13, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CARVEDILOL PHOSPHATE ER 20 MG PO CP24", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "57664066483", "type": "NDC" } ], "standard_charges": [ { "minimum": 4.31, "maximum": 14.38, "gross_charge": 15.3, "discounted_cash": 8.42, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.87, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.35, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.24, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.96, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.45, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.34, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.16, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.15, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.38, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.46, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.31, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.01, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.48, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.39, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.4, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.38, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.98, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.35, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.16, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.48, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.46, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.87, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.35, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CARVEDILOL PHOSPHATE ER 40 MG PO CP24", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "57664066583", "type": "NDC" } ], "standard_charges": [ { "minimum": 3.46, "maximum": 11.54, "gross_charge": 12.28, "discounted_cash": 6.75, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.12, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.7, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.82, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.57, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.89, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.36, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.34, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.54, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.81, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.46, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.44, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.21, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.33, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.35, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.54, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.62, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.7, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.76, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.21, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.81, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.12, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.7, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CASPOFUNGIN 250 MCG/0.1 ML INTRAVITREAL INJECTION SOLUTION", "drug_information": { "unit": "0.100000", "type": "UN" }, "code_information": [ { "code": "08252000294", "type": "NDC" } ], "standard_charges": [ { "minimum": 23.97, "maximum": 79.95, "gross_charge": 85.05, "discounted_cash": 46.78, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.33, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.44, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 68.04, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 72.04, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.75, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.82, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.94, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.86, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 79.95, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.84, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.97, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 72.29, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.79, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.96, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 57.83, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 79.95, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 66.59, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.44, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 67.61, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.79, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.84, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.33, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.44, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CASPOFUNGIN ACETATE 50 MG IV SOLR", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "72266010601", "type": "NDC" } ], "standard_charges": [ { "minimum": 23.95, "maximum": 79.9, "gross_charge": 85.0, "discounted_cash": 46.75, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.3, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.41, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 68.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 72.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.74, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.83, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 79.9, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.95, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 72.25, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.95, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 57.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 79.9, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 66.56, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.41, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 67.58, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.3, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.41, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CASPOFUNGIN ACETATE 70 MG IV SOLR", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "00006382310", "type": "NDC" } ], "standard_charges": [ { "minimum": 45.68, "maximum": 152.36, "gross_charge": 162.09, "discounted_cash": 89.15, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 94.01, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.5, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 129.67, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 137.29, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.17, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 77.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 97.09, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.93, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 152.36, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 142.64, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.68, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 137.78, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 121.57, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 57.1, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 110.22, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 152.36, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 126.92, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.5, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 128.86, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 121.57, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 142.64, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 94.01, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.5, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CASPOFUNGIN OPHTHALMIC SOLN 0.5%", "drug_information": { "unit": "0.050000", "type": "UN" }, "code_information": [ { "code": "08252000141", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CASTOR OIL OIL", "drug_information": { "unit": "59.000000", "type": "UN" }, "code_information": [ { "code": "00395051592", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.13, "maximum": 7.1, "gross_charge": 7.55, "discounted_cash": 4.15, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.38, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.12, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.04, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.2, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.62, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.52, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.51, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.1, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.64, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.42, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.66, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.66, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.13, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.1, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.91, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.12, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.66, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.64, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.38, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.12, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Catheter for hysterography", "code_information": [ { "code": "58340", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 590.24, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 1125.01, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 1125.01, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CEFADROXIL 500 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00093319653", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CEFADROXIL 500 MG/5ML PO SUSR", "drug_information": { "unit": "75.000000", "type": "UN" }, "code_information": [ { "code": "65862008475", "type": "NDC" } ], "standard_charges": [ { "minimum": 32.22, "maximum": 107.49, "gross_charge": 114.35, "discounted_cash": 62.89, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 66.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 62.44, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 91.48, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.85, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.28, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.89, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 68.5, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 68.38, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 107.49, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 100.63, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.22, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 97.2, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 85.76, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.29, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 77.76, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 107.49, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 89.54, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 62.44, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 90.91, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 85.76, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 100.63, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 66.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 62.44, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CEFAZOLIN 100 MG/ML SYRINGE", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "00143992490_7", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CEFAZOLIN 100 MG/ML SYRINGE|DISCARDED DRUG NOT ADMINISTERED", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "00143992490", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.38, "maximum": 1.28, "gross_charge": 1.36, "discounted_cash": 0.75, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.79, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.74, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.09, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.15, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.4, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.65, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.81, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.81, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.28, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.38, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.02, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.92, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.28, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.06, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.74, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.08, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.02, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.79, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.74, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CEFAZOLIN 330 MG/ML IM INJECTION", "drug_information": { "unit": "3.100000", "type": "UN" }, "code_information": [ { "code": "00143992490_8", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CEFAZOLIN 330 MG/ML IM INJECTION|DISCARDED DRUG NOT ADMINISTERED", "drug_information": { "unit": "3.100000", "type": "UN" }, "code_information": [ { "code": "00143992490_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.38, "maximum": 1.28, "gross_charge": 1.36, "discounted_cash": 0.75, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.79, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.74, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.09, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.15, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.4, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.65, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.81, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.81, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.28, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.38, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.02, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.92, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.28, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.06, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.74, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.08, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.02, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.79, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.74, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CEFAZOLIN INTRAVITREAL INJ (2MG/0.1ML)", "drug_information": { "unit": "0.100000", "type": "UN" }, "code_information": [ { "code": "08252002000", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CEFAZOLIN OPHTHALMIC SOLN 100 MG/ML", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "08252002200", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 1158.0, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 95.48, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CEFAZOLIN OPHTHALMIC SOLN 50 MG/ML", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "08252002100", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 1158.0, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 95.48, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CEFAZOLIN SODIUM 1 G IJ SOLR", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "00143992490_5", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CEFAZOLIN SODIUM 1 G IJ SOLR (INTRA-ARTICULAR ONLY)", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "00143992490_6", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CEFAZOLIN SODIUM 1 G IJ SOLR (INTRA-ARTICULAR ONLY)|DISCARDED DRUG NOT ADMINISTERED", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "00143992490_3", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.38, "maximum": 1.28, "gross_charge": 1.36, "discounted_cash": 0.75, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.79, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.74, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.09, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.15, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.4, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.65, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.81, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.81, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.28, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.38, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.02, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.92, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.28, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.06, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.74, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.08, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.02, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.79, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.74, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CEFAZOLIN SODIUM 1 G IJ SOLR|DISCARDED DRUG NOT ADMINISTERED", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "00143992490_4", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.38, "maximum": 1.28, "gross_charge": 1.36, "discounted_cash": 0.75, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.79, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.74, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.09, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.15, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.4, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.65, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.81, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.81, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.28, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.38, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.02, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.92, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.28, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.06, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.74, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.08, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.02, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.79, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.74, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CEFAZOLIN SODIUM 10 G IJ SOLR", "drug_information": { "unit": "100.000000", "type": "UN" }, "code_information": [ { "code": "00143998303", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CEFAZOLIN SODIUM 50 MG/ML IJ SOLR", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "00781345095", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CEFAZOLIN SODIUM 500 MG IJ SOLR", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "00781345095_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CEFAZOLIN SODIUM-DEXTROSE 1-4 GM-%(50ML) IV SOLR", "drug_information": { "unit": "50.000000", "type": "UN" }, "code_information": [ { "code": "00264310311", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CEFAZOLIN SODIUM-DEXTROSE 1-4 GM/50ML-% IV SOLN", "drug_information": { "unit": "50.000000", "type": "UN" }, "code_information": [ { "code": "00338350341", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CEFAZOLIN SODIUM-DEXTROSE 2-3 GM-%(50ML) IV SOLR", "drug_information": { "unit": "50.000000", "type": "UN" }, "code_information": [ { "code": "00264310511", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CEFAZOLIN SODIUM-DEXTROSE 2-4 GM/100ML-% IV SOLN", "drug_information": { "unit": "100.000000", "type": "UN" }, "code_information": [ { "code": "00338350841", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CEFAZOLIN SUBCONJUNCTIVAL INJ (100 MG/0.44 ML)", "drug_information": { "unit": "0.440000", "type": "UN" }, "code_information": [ { "code": "08252001300", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CEFDINIR 125 MG/5ML PO SUSR", "drug_information": { "unit": "60.000000", "type": "UN" }, "code_information": [ { "code": "68180072204", "type": "NDC" } ], "standard_charges": [ { "minimum": 12.77, "maximum": 42.58, "gross_charge": 45.3, "discounted_cash": 24.92, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.27, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.73, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.24, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.37, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.18, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.74, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.13, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.09, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.58, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.86, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.77, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.51, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.98, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.96, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.58, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.47, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.73, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.01, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.98, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.86, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.27, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.73, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CEFDINIR 300 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00093316006", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.45, "maximum": 8.17, "gross_charge": 8.69, "discounted_cash": 4.78, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.04, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.74, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.95, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.36, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.53, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.17, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.21, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.2, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.17, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.65, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.45, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.52, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.06, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.91, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.17, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.8, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.74, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.91, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.52, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.65, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.04, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.74, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CEFEPIME 1 GM/50 ML RTU", "drug_information": { "unit": "50.000000", "type": "UN" }, "code_information": [ { "code": "00338130141", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CEFEPIME 100 MG/ML SYRINGE", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "00409956610_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CEFEPIME 2 GM/100 ML RTU", "drug_information": { "unit": "100.000000", "type": "UN" }, "code_information": [ { "code": "00338130148", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CEFEPIME 20 MG/ML IVPB RTU (PEDS)", "drug_information": { "unit": "50.000000", "type": "UN" }, "code_information": [ { "code": "00338130141_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CEFEPIME 20 MG/ML SYRINGE RTU (PEDS)", "drug_information": { "unit": "50.000000", "type": "UN" }, "code_information": [ { "code": "00338130141_3", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CEFEPIME HCL 1 G IJ SOLR", "drug_information": { "unit": "11.000000", "type": "UN" }, "code_information": [ { "code": "00409956610", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CEFEPIME HCL 2 G IV SOLR", "drug_information": { "unit": "13.000000", "type": "UN" }, "code_information": [ { "code": "00409973510", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CEFEPIME-DEXTROSE 1-5 GM-%(50ML) IV SOLR", "drug_information": { "unit": "50.000000", "type": "UN" }, "code_information": [ { "code": "00264319311", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CEFEPIME-DEXTROSE 2-5 GM-%(50ML) IV SOLR", "drug_information": { "unit": "50.000000", "type": "UN" }, "code_information": [ { "code": "00264319511", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CEFIDEROCOL SULFATE TOSYLATE 1 G IV SOLR", "drug_information": { "unit": "11.200000", "type": "UN" }, "code_information": [ { "code": "59630026610", "type": "NDC" } ], "standard_charges": [ { "minimum": 196.22, "maximum": 654.54, "gross_charge": 696.32, "discounted_cash": 382.98, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 403.87, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 380.19, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 557.06, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 589.78, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 202.63, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 334.23, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 417.1, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 416.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 654.54, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 612.76, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 196.22, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 591.87, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 522.24, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 245.31, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 473.5, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 654.54, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 545.22, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 380.19, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 553.57, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 522.24, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 612.76, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 403.87, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 380.19, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CEFIXIME 100 MG/5ML PO SUSR", "drug_information": { "unit": "50.000000", "type": "UN" }, "code_information": [ { "code": "65862075150", "type": "NDC" } ], "standard_charges": [ { "minimum": 49.32, "maximum": 164.5, "gross_charge": 175.0, "discounted_cash": 96.25, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 101.5, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 95.55, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 140.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 148.23, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.93, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 84.0, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 104.83, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 104.65, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 164.5, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 154.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.32, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 148.75, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 131.25, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.65, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 119.0, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 164.5, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 137.03, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 95.55, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 139.13, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 131.25, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 154.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 101.5, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 95.55, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CEFIXIME 400 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68180042311", "type": "NDC" } ], "standard_charges": [ { "minimum": 6.58, "maximum": 21.96, "gross_charge": 23.36, "discounted_cash": 12.85, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.55, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.75, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.69, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.79, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.8, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.21, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.99, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.97, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.96, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.56, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.58, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.86, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.52, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.23, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.88, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.96, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.29, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.75, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.57, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.52, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.56, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.55, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.75, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CEFOTAXIME SODIUM 1 G IJ SOLR", "drug_information": { "unit": "10.530000", "type": "UN" }, "code_information": [ { "code": "21586001102", "type": "NDC" } ], "standard_charges": [ { "minimum": 246.58, "maximum": 822.5, "gross_charge": 875.0, "discounted_cash": 481.25, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 507.5, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 477.75, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 700.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 741.13, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 254.63, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 420.0, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 524.13, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 523.25, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 822.5, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 770.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 246.58, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 743.75, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 656.25, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 308.26, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 595.0, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 822.5, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 685.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 477.75, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 695.63, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 656.25, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 770.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 507.5, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 477.75, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CEFOTAXIME SODIUM 1 G IJ SOLR (POWDER)", "drug_information": { "unit": "1000.000000", "type": "ME" }, "code_information": [ { "code": "21586001102_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 246.58, "maximum": 822.5, "gross_charge": 875.0, "discounted_cash": 481.25, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 507.5, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 477.75, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 700.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 741.13, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 254.63, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 420.0, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 524.13, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 523.25, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 822.5, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 770.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 246.58, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 743.75, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 656.25, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 308.26, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 595.0, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 822.5, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 685.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 477.75, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 695.63, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 656.25, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 770.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 507.5, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 477.75, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CEFOTETAN DISODIUM 1 G IJ SOLR", "drug_information": { "unit": "0.500000", "type": "GR" }, "code_information": [ { "code": "63323038510", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 1158.0, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.72, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CEFOTETAN DISODIUM 2 G IJ SOLR", "drug_information": { "unit": "2.000000", "type": "GR" }, "code_information": [ { "code": "63323038620", "type": "NDC" } ], "standard_charges": [ { "minimum": 12.81, "maximum": 1158.0, "gross_charge": 45.45, "discounted_cash": 25.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.36, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.82, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.45, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.23, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.82, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.22, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.18, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.72, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.81, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.63, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.09, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.01, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.91, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.72, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.59, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.82, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.13, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.09, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.36, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.82, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CEFOXITIN SODIUM 1 G IV SOLR", "drug_information": { "unit": "11.000000", "type": "UN" }, "code_information": [ { "code": "25021010910", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CEFOXITIN SODIUM 2 G IV SOLR", "drug_information": { "unit": "21.000000", "type": "UN" }, "code_information": [ { "code": "44567024625", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CEFOXITIN SODIUM-DEXTROSE 2-2.2 GM-%(50ML) IV SOLR", "drug_information": { "unit": "50.000000", "type": "UN" }, "code_information": [ { "code": "00264312511", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CEFPODOXIME PROXETIL 100 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00781543820", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.34, "maximum": 4.46, "gross_charge": 4.74, "discounted_cash": 2.61, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.75, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.59, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.79, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.01, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.38, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.28, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.84, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.83, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.46, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.17, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.34, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.03, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.56, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.67, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.22, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.46, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.71, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.59, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.77, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.56, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.17, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.75, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.59, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CEFPODOXIME PROXETIL 100 MG/5ML PO SUSR", "drug_information": { "unit": "100.000000", "type": "UN" }, "code_information": [ { "code": "64980040310", "type": "NDC" } ], "standard_charges": [ { "minimum": 70.62, "maximum": 235.56, "gross_charge": 250.6, "discounted_cash": 137.83, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 145.35, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 136.83, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 200.48, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 212.26, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 72.92, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 120.29, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 150.11, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 149.86, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 235.56, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 220.53, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 70.62, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 213.01, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 187.95, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.29, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 170.41, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 235.56, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 196.22, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 136.83, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 199.23, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 187.95, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 220.53, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 145.35, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 136.83, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CEFPODOXIME PROXETIL 200 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "1671439501", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.05, "maximum": 6.83, "gross_charge": 7.27, "discounted_cash": 4.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.22, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.97, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.82, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.16, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.12, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.49, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.35, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.35, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.83, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.4, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.05, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.18, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.45, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.56, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.94, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.83, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.69, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.97, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.78, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.45, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.4, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.22, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.97, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CEFPODOXIME PROXETIL 50 MG/5ML PO SUSR", "drug_information": { "unit": "100.000000", "type": "UN" }, "code_information": [ { "code": "65862014001", "type": "NDC" } ], "standard_charges": [ { "minimum": 45.09, "maximum": 150.4, "gross_charge": 160.0, "discounted_cash": 88.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 92.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.36, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 128.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 135.52, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.56, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 76.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 95.84, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 95.68, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 150.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 140.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.09, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 136.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 120.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 56.37, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 108.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 150.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 125.28, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.36, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 127.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 120.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 140.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 92.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.36, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CEFPROZIL 125 MG/5ML PO SUSR", "drug_information": { "unit": "100.000000", "type": "UN" }, "code_information": [ { "code": "68180040103", "type": "NDC" } ], "standard_charges": [ { "minimum": 9.36, "maximum": 31.21, "gross_charge": 33.2, "discounted_cash": 18.26, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.26, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.13, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.56, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.12, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.66, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.94, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.85, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.21, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.22, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.36, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.22, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.9, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.7, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.58, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.21, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.0, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.13, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.39, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.9, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.22, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.26, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.13, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CEFPROZIL 250 MG/5ML PO SUSR", "drug_information": { "unit": "100.000000", "type": "UN" }, "code_information": [ { "code": "68180040203", "type": "NDC" } ], "standard_charges": [ { "minimum": 36.29, "maximum": 121.05, "gross_charge": 128.78, "discounted_cash": 70.83, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.69, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 70.31, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.02, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 109.08, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.47, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.81, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 77.14, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 77.01, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 121.05, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 113.33, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.29, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 109.46, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.59, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.37, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.57, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 121.05, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 100.83, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 70.31, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 102.38, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.59, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 113.33, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.69, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 70.31, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CEFTAROLINE FOSAMIL 600 MG IV SOLR", "drug_information": { "unit": "20.000000", "type": "UN" }, "code_information": [ { "code": "00456060010", "type": "NDC" } ], "standard_charges": [ { "minimum": 212.47, "maximum": 708.72, "gross_charge": 753.96, "discounted_cash": 414.68, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 437.3, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 411.66, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 603.17, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 638.6, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 219.4, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 361.9, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 451.62, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 450.87, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 708.72, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 663.48, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 212.47, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 640.87, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 565.47, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 265.62, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 512.69, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 708.72, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 590.35, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 411.66, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 599.4, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 565.47, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 663.48, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 437.3, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 411.66, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CEFTAZIDIME 1 G IJ SOLR", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "44567023525", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CEFTAZIDIME 1 G IV SOLR", "drug_information": { "unit": "1.000000", "type": "GR" }, "code_information": [ { "code": "00409509216", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CEFTAZIDIME 100 MG/ML SYRINGE", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "44567023525_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CEFTAZIDIME INTRAVITREAL INJ (2.25MG/0.05ML)", "drug_information": { "unit": "0.050000", "type": "UN" }, "code_information": [ { "code": "08252002300", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CEFTAZIDIME INTRAVITREAL INJ (2.25MG/0.1ML)", "drug_information": { "unit": "0.100000", "type": "UN" }, "code_information": [ { "code": "08252002400", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CEFTAZIDIME OPHTHALMIC SOLN 50 MG/ML", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "08252002510", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 1158.0, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 95.48, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CEFTAZIDIME SUBCONJUNCTIVAL INJ (200 MG/0.5 ML)", "drug_information": { "unit": "0.500000", "type": "UN" }, "code_information": [ { "code": "08252001000", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CEFTAZIDIME-AVIBACTAM 2.5 (2-0.5) G IV SOLR", "drug_information": { "unit": "12.000000", "type": "UN" }, "code_information": [ { "code": "00456270010", "type": "NDC" } ], "standard_charges": [ { "minimum": 54.92, "maximum": 1279.79, "gross_charge": 1361.48, "discounted_cash": 748.81, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 789.66, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.92, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1089.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1153.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 396.19, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 653.51, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 815.53, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 814.17, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1279.79, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1198.1, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 383.67, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1157.26, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1021.11, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 479.65, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 925.81, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1279.79, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1066.04, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.14, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1082.38, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1021.11, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1198.1, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 789.66, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.92, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "CEFTOLOZANE-TAZOBACTAM 1.5 (1-0.5) G IV SOLR", "drug_information": { "unit": "11.400000", "type": "UN" }, "code_information": [ { "code": "67919003001", "type": "NDC" } ], "standard_charges": [ { "minimum": 4.49, "maximum": 472.73, "gross_charge": 502.9, "discounted_cash": 276.6, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 291.68, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.49, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 402.32, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 425.96, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 146.34, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 241.39, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 301.24, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 300.73, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 472.73, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 442.55, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 141.72, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 427.47, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 377.18, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 177.17, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 341.97, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 472.73, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 393.77, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.07, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 399.81, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 377.18, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 442.55, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 291.68, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.49, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "CEFTRIAXONE 1 GM/50 ML RTU", "drug_information": { "unit": "50.000000", "type": "UN" }, "code_information": [ { "code": "00338500241", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CEFTRIAXONE 100 MG/ML SYRINGE", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "00409733201_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CEFTRIAXONE 2 GM/50 ML RTU", "drug_information": { "unit": "50.000000", "type": "UN" }, "code_information": [ { "code": "00338500341", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CEFTRIAXONE 40 MG/ML SYRINGE-RTU (PEDS)", "drug_information": { "unit": "50.000000", "type": "UN" }, "code_information": [ { "code": "00338500341_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 32.56, "maximum": 108.6, "gross_charge": 115.53, "discounted_cash": 63.54, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 67.01, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.08, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 92.42, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 97.85, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.62, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.45, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 69.2, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 69.09, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 108.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 101.67, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.56, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 98.2, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.65, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.7, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 78.56, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 108.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 90.46, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.08, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 91.85, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.65, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 101.67, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 67.01, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.08, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CEFTRIAXONE SODIUM 1 G IJ SOLR", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "00409733201", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CEFTRIAXONE SODIUM 1 G IV SOLR", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "00409733349", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CEFTRIAXONE SODIUM 2 G IJ SOLR", "drug_information": { "unit": "20.000000", "type": "UN" }, "code_information": [ { "code": "00409733503", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CEFTRIAXONE SODIUM 250 MG IJ SOLR", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00409733701", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CEFTRIAXONE SODIUM 500 MG IJ SOLR", "drug_information": { "unit": "500.000000", "type": "ME" }, "code_information": [ { "code": "60505615201", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CEFTRIAXONE SODIUM-DEXTROSE 1-3.74 GM-%(50ML) IV SOLR", "drug_information": { "unit": "50.000000", "type": "UN" }, "code_information": [ { "code": "00264315311", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CEFTRIAXONE SODIUM-DEXTROSE 2-2.22 GM-%(50ML) IV SOLR", "drug_information": { "unit": "50.000000", "type": "UN" }, "code_information": [ { "code": "00264315511", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CEFUROXIME 100 MG/ML SYRINGE", "drug_information": { "unit": "15.000000", "type": "UN" }, "code_information": [ { "code": "08252002518", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CEFUROXIME AXETIL 250 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68180030260", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CEFUROXIME INTRACAMERAL INJ (1 MG/0.1ML)", "drug_information": { "unit": "1.000000", "type": "ME" }, "code_information": [ { "code": "08252000027", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CEFUROXIME SODIUM 1.5 G IV SOLR", "drug_information": { "unit": "1.500000", "type": "GR" }, "code_information": [ { "code": "00143997722", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CEFUROXIME SODIUM 750 MG IJ SOLR", "drug_information": { "unit": "750.000000", "type": "ME" }, "code_information": [ { "code": "00143997922", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CELECOXIB 100 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687043601", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CELECOXIB 200 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687044701", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CELECOXIB 50 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "62332014060", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CEMIPLIMAB-RWLC 350 MG/7ML IV SOLN", "drug_information": { "unit": "7.000000", "type": "UN" }, "code_information": [ { "code": "61755000801", "type": "NDC" } ], "standard_charges": [ { "minimum": 8966.95, "maximum": 29911.06, "gross_charge": 31820.28, "discounted_cash": 17501.15, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 18455.76, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 17373.87, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 25456.22, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 26951.78, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9259.7, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15273.73, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 19060.35, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 11394.0, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 29911.06, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 28001.85, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 8966.95, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 27047.24, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23865.21, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11210.28, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 21637.79, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 29911.06, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24915.28, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 17373.87, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 15189.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23865.21, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 28001.85, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 18455.76, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 17373.87, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CENOBAMATE 100 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "R7169910030", "type": "NDC" } ], "standard_charges": [ { "minimum": 25.1, "maximum": 83.72, "gross_charge": 89.06, "discounted_cash": 48.98, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 51.65, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 48.63, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 71.25, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.43, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.92, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.75, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 53.35, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 53.26, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 83.72, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 78.37, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.1, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.7, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 66.8, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.38, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.56, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 83.72, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 69.73, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 48.63, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 70.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 66.8, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 78.37, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 51.65, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 48.63, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CENOBAMATE 12.5 MG PO TABS (INPATIENT USE ONLY)", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "R7169902530", "type": "NDC" } ], "standard_charges": [ { "minimum": 25.1, "maximum": 83.72, "gross_charge": 89.06, "discounted_cash": 48.98, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 51.65, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 48.63, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 71.25, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.43, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.92, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.75, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 53.35, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 53.26, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 83.72, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 78.37, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.1, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.7, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 66.8, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.38, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.56, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 83.72, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 69.73, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 48.63, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 70.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 66.8, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 78.37, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 51.65, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 48.63, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CEPHALEXIN 125 MG/5ML PO SUSR", "drug_information": { "unit": "100.000000", "type": "UN" }, "code_information": [ { "code": "00093417573", "type": "NDC" } ], "standard_charges": [ { "minimum": 4.02, "maximum": 13.42, "gross_charge": 14.28, "discounted_cash": 7.85, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.28, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.8, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.42, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.1, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.85, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.55, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.54, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.42, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.57, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.02, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.14, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.71, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.03, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.71, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.42, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.18, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.8, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.35, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.71, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.57, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.28, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.8, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CEPHALEXIN 250 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "50268015115", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CEPHALEXIN 250 MG/5ML PO SUSR", "drug_information": { "unit": "100.000000", "type": "UN" }, "code_information": [ { "code": "67877054588", "type": "NDC" } ], "standard_charges": [ { "minimum": 8.27, "maximum": 27.57, "gross_charge": 29.33, "discounted_cash": 16.13, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.01, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.01, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.46, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.84, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.54, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.08, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.57, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.54, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.57, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.81, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.93, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.33, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.94, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.57, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.97, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.01, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.32, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.81, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.01, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.01, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CEPHALEXIN 500 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687016301", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CERTOLIZUMAB PEGOL 2 X 200 MG SC KIT", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "50474070062", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.54, "maximum": 8064.06, "gross_charge": 8578.79, "discounted_cash": 4718.33, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4975.7, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.54, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6863.03, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7266.24, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2496.43, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4117.82, "standard_charge_percentage": 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"additional_payer_notes": "N/A", "standard_charge_dollar": 7213.01, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2309.8, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6967.11, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6147.45, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2887.66, "standard_charge_percentage": 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6516.3, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6147.45, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7213.01, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4754.03, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.54, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "Cervical laminoplsty 2/> 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"CETAPHIL EX LIQD", "drug_information": { "unit": "237.000000", "type": "UN" }, "code_information": [ { "code": "00299392708", "type": "NDC" } ], "standard_charges": [ { "minimum": 4.49, "maximum": 14.99, "gross_charge": 15.95, "discounted_cash": 8.77, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.25, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.71, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.76, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", 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"payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.99, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.49, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.56, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.96, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.62, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.85, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.99, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.49, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.71, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.68, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.96, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.25, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.71, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CETIRIZINE HCL 1 MG/ML PO SOLN", "drug_information": { "unit": "2.500000", "type": "UN" }, "code_information": [ { "code": "51672407008", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CETIRIZINE HCL 10 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "51079059720", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CETIRIZINE HCL 5 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "R1657140110", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CETRORELIX ACETATE 0.25 MG SC KIT", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "44087122501", "type": "NDC" } ], "standard_charges": [ { "minimum": 307.36, "maximum": 1158.0, "gross_charge": 1090.72, "discounted_cash": 599.9, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 632.62, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 595.53, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 946.74, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 317.4, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 523.55, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 653.34, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 652.25, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1025.28, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 959.83, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 307.36, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 927.11, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 818.04, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 384.26, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 741.69, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1025.28, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 854.03, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 595.53, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 867.12, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 818.04, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 959.83, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 632.62, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 595.53, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CETUXIMAB 100 MG/50ML IV SOLN", "drug_information": { "unit": "50.000000", "type": "UN" }, "code_information": [ { "code": "66733094823_3", "type": "NDC" } ], "standard_charges": [ { "minimum": 41.21, "maximum": 2932.69, "gross_charge": 3119.88, "discounted_cash": 1715.93, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1809.53, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.21, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2495.9, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2642.54, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 907.89, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1497.54, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1868.81, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 1865.69, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2932.69, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2745.49, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 879.18, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2651.9, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2339.91, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1099.13, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2121.52, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2932.69, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2442.87, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2480.3, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2339.91, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2745.49, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1809.53, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.21, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "CETUXIMAB 200 MG/100ML IV SOLN", "drug_information": { "unit": "100.000000", "type": "UN" }, "code_information": [ { "code": "66733095823", "type": "NDC" } ], "standard_charges": [ { "minimum": 41.21, "maximum": 4107.39, "gross_charge": 4369.56, "discounted_cash": 2403.26, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2534.34, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.21, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3495.65, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3701.02, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1271.54, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2097.39, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2617.37, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2613.0, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4107.39, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3845.21, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1231.34, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3714.13, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3277.17, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1539.4, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2971.3, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4107.39, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3421.37, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3473.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3277.17, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3845.21, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2534.34, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.21, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "CETUXIMAB INFUSION", "drug_information": { "unit": "50.000000", "type": "UN" }, "code_information": [ { "code": "66733094823_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 41.21, "maximum": 1898.73, "gross_charge": 2019.93, "discounted_cash": 1110.96, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1171.56, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.21, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1615.94, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1710.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 587.8, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 969.57, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1209.94, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 1207.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1898.73, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1777.54, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 569.22, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1716.94, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1514.95, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 711.62, 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"N/A", "standard_charge_dollar": 1605.84, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1514.95, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1777.54, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1171.56, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.21, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "CETUXIMAB INFUSION|DISCARDED DRUG NOT ADMINISTERED", "drug_information": { "unit": "50.000000", "type": "UN" }, "code_information": [ { "code": "66733094823", "type": "NDC" } ], "standard_charges": [ { "minimum": 41.21, "maximum": 1832.93, "gross_charge": 1949.93, "discounted_cash": 1072.46, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1130.96, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.21, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1559.94, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1651.59, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 567.43, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 935.97, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1168.01, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 1166.06, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1832.93, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1715.94, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 549.49, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1657.44, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1462.45, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 686.96, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1325.95, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1832.93, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1526.8, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1550.19, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1462.45, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1715.94, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1130.96, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.21, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "CEVIMELINE HCL 30 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00054033425", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Change g-tube to g-j perc", "code_information": [ { "code": "49446", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1398.27, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1035.76, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 14275.06, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 25902.36, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1398.27, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 25902.36, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Change nephroureteral cath", "code_information": [ { "code": "50387", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1509.96, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1118.49, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 7163.54, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 12998.39, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1509.96, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 12998.39, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Change of ureter tube/stent", "code_information": [ { "code": "50688", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1509.96, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1118.49, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 7058.93, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 12808.54, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1509.96, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 12808.54, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Change ureter stent percut", "code_information": [ { "code": "50382", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1509.96, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1118.49, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 11937.19, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 21660.23, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1509.96, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 21660.23, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CHARCOAL ACTIVATED PO LIQD", "drug_information": { "unit": "120.000000", "type": "UN" }, "code_information": [ { "code": "00574052174", "type": "NDC" } ], "standard_charges": [ { "minimum": 7.33, "maximum": 24.44, "gross_charge": 26.0, "discounted_cash": 14.3, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.08, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.2, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.02, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.57, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.48, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.57, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.55, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.44, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.88, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.33, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.1, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.16, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.68, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.44, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.36, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.2, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.67, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.88, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.08, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.2, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Chemodener muscle larynx emg", "code_information": [ { "code": "64617", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 510.46, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 378.12, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 12529.23, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 22772.86, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 510.46, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 22772.86, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Chemodenerv 1 extremity 1-4", "code_information": [ { "code": "64642", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 510.46, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 378.12, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 3548.38, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 6438.6, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 510.46, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 6438.6, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Chemodenerv musc migraine", "code_information": [ { "code": "64615", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 217.58, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 505.92, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 918.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 217.58, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 918.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Chemodenerv musc neck dyston", "code_information": [ { "code": "64616", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 217.58, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 161.17, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 2953.18, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 5358.6, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 217.58, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 5358.6, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Chemodenerv saliv glands", "code_information": [ { "code": "64611", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 217.58, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 161.17, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 2253.82, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 4089.6, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 217.58, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 4089.6, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Chemodenerv trunk musc 1-5", "code_information": [ { "code": "64646", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 510.46, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 378.12, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 6560.41, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 11903.98, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 510.46, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 11903.98, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Chemodenervation anal musc", "code_information": [ { "code": "46505", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 869.1, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 643.78, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 5795.25, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 10515.6, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 869.1, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 10515.6, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CHERRY PO SYRP", "drug_information": { "unit": "473.000000", "type": "UN" }, "code_information": [ { "code": "31722093847", "type": "NDC" } ], "standard_charges": [ { "minimum": 7.51, "maximum": 25.05, "gross_charge": 26.65, "discounted_cash": 14.66, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.46, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.55, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.32, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.57, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.76, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.79, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.94, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.05, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.45, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.51, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.65, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.99, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.39, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.12, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.05, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.87, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.55, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.19, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.99, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.45, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.46, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.55, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CHLORAL HYDRATE 500 MG/5ML PO SYRUP", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "P5155252805", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.25, "maximum": 7.52, "gross_charge": 8.0, "discounted_cash": 4.4, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.4, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.78, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.33, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.84, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.79, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.25, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.8, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.82, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.44, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.26, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.36, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CHLORDIAZEPOXIDE HCL 10 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "R0555003302", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.25, "maximum": 7.52, "gross_charge": 8.0, "discounted_cash": 4.4, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.4, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.78, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.33, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.84, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.79, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.25, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.8, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.82, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.44, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.26, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.36, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CHLORDIAZEPOXIDE HCL 25 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "51079014120", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.25, "maximum": 7.52, "gross_charge": 8.0, "discounted_cash": 4.4, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.4, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.78, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.33, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.84, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.79, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.25, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.8, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.82, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.44, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.26, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.36, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CHLORDIAZEPOXIDE HCL 5 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "51079037420", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.25, "maximum": 7.52, "gross_charge": 8.0, "discounted_cash": 4.4, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.4, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.78, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.33, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.84, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.79, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.25, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.8, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.82, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.44, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.26, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.36, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CHLORHEXIDINE GLUCONATE (DRESSING) EX MISC", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "56091004150", "type": "NDC" } ], "standard_charges": [ { "minimum": 5.47, "maximum": 18.24, "gross_charge": 19.4, "discounted_cash": 10.67, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.25, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.59, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.52, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.43, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.65, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.31, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.62, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.6, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.24, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.07, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.47, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.49, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.55, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.83, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.19, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.24, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.19, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.59, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.42, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.55, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.07, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.25, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.59, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CHLORHEXIDINE GLUCONATE 0.12 % MT SOLN", "drug_information": { "unit": "15.000000", "type": "UN" }, "code_information": [ { "code": "17856027202", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CHLOROPROCAINE HCL (PF) 2 % IJ SOLN", "drug_information": { "unit": "20.000000", "type": "UN" }, "code_information": [ { "code": "63323047727", "type": "NDC" } ], "standard_charges": [ { "minimum": 12.78, "maximum": 42.63, "gross_charge": 45.35, "discounted_cash": 24.94, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.3, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.76, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.28, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.41, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.2, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.77, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.16, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.12, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.63, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.91, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.78, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.55, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.01, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.98, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.84, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.63, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.51, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.76, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.05, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.01, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.91, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.3, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.76, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CHLOROPROCAINE HCL (PF) 3 % IJ SOLN", "drug_information": { "unit": "20.000000", "type": "UN" }, "code_information": [ { "code": "63323047827", "type": "NDC" } ], "standard_charges": [ { "minimum": 13.42, "maximum": 44.78, "gross_charge": 47.64, "discounted_cash": 26.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.63, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.01, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.11, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.35, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.86, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.87, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.54, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.49, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 44.78, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.92, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.42, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.49, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.73, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.78, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.4, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 44.78, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.3, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.01, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.87, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.73, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.92, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.63, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.01, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CHLOROQUINE PHOSPHATE 250 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "64980017750", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.98, "maximum": 6.6, "gross_charge": 7.02, "discounted_cash": 3.86, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.07, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.83, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.62, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.95, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.04, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.37, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.2, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.2, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.18, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.98, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.97, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.27, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.47, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.77, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.5, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.83, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.58, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.27, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.18, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.07, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.83, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CHLOROQUINE PHOSPHATE 500 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "64980017802", "type": "NDC" } ], "standard_charges": [ { "minimum": 5.13, "maximum": 17.11, "gross_charge": 18.2, "discounted_cash": 10.01, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.56, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.94, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.56, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.42, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.3, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.74, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.9, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.88, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.11, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.02, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.47, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.65, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.38, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.11, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.25, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.94, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.47, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.65, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.02, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.56, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.94, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CHLOROTHIAZIDE 250 MG/5ML PO SUSP", "drug_information": { "unit": "237.000000", "type": "UN" }, "code_information": [ { "code": "65649031112", "type": "NDC" } ], "standard_charges": [ { "minimum": 43.99, "maximum": 146.73, "gross_charge": 156.1, "discounted_cash": 85.86, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 90.54, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 85.23, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 124.88, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 132.22, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.43, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.93, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.35, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 146.73, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 137.37, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.99, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 132.69, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 117.08, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.99, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 106.15, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 146.73, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 122.23, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 85.23, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 124.1, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 117.08, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 137.37, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 90.54, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 85.23, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CHLOROTHIAZIDE 28 MG/ML SYRINGE", "drug_information": { "unit": "18.000000", "type": "UN" }, "code_information": [ { "code": "00517182001_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 62.26, "maximum": 207.69, "gross_charge": 220.95, "discounted_cash": 121.52, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 128.15, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 120.64, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 176.76, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 187.14, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 64.3, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 106.06, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 132.35, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 132.13, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 207.69, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 194.44, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 62.26, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 187.81, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 165.71, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 77.84, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 150.25, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 207.69, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 173.0, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 120.64, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 175.66, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 165.71, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 194.44, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 128.15, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 120.64, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CHLOROTHIAZIDE SODIUM 500 MG IV SOLR", "drug_information": { "unit": "17.850000", "type": "UN" }, "code_information": [ { "code": "00517182001", "type": "NDC" } ], "standard_charges": [ { "minimum": 21.27, "maximum": 70.95, "gross_charge": 75.48, "discounted_cash": 41.51, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.78, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.21, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.38, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.93, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.96, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.23, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.21, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.14, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 70.95, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 66.42, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 64.16, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 56.61, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.59, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 51.33, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 70.95, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.1, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.21, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.01, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 56.61, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 66.42, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.78, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.21, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CHLORPROMAZINE HCL 10 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687041901", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.33, "maximum": 4.43, "gross_charge": 4.71, "discounted_cash": 2.59, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.73, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.77, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.99, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.37, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.26, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.82, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.82, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.43, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.14, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.33, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.53, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.66, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.43, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.69, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.74, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.53, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.14, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.73, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CHLORPROMAZINE HCL 100 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687045201", "type": "NDC" } ], "standard_charges": [ { "minimum": 3.24, "maximum": 10.79, "gross_charge": 11.48, "discounted_cash": 6.31, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.66, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.27, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.72, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.34, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.51, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.88, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.87, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.79, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.1, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.24, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.76, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.61, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.04, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.81, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.79, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.99, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.27, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.13, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.61, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.1, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.66, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.27, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CHLORPROMAZINE HCL 25 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687043001", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.7, "maximum": 5.68, "gross_charge": 6.04, "discounted_cash": 3.32, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.5, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.3, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.83, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.12, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.76, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.9, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.62, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.61, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.68, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.32, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.7, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.13, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.53, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.13, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.11, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.68, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.73, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.3, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.53, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.32, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.5, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.3, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CHLORPROMAZINE HCL 25 MG/ML IJ SOLN", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00641139735", "type": "NDC" } ], "standard_charges": [ { "minimum": 17.51, "maximum": 58.41, "gross_charge": 62.14, "discounted_cash": 34.18, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.04, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.93, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.71, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.63, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.08, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.83, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.22, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.16, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 58.41, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.68, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.51, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.82, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.61, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.89, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.26, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 58.41, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 48.66, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.93, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.4, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.61, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.68, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.04, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.93, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CHLORPROMAZINE HCL 50 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "50268016415", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.52, "maximum": 5.07, "gross_charge": 5.39, "discounted_cash": 2.96, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.94, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.31, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.57, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.57, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.59, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.23, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.22, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.07, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.74, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.52, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.58, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.04, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.9, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.67, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.07, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.22, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.94, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.29, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.04, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.74, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.94, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CHLORPROMAZINE HCL 50 MG/2ML IJ SOLN", "drug_information": { "unit": "2.000000", "type": "UN" }, "code_information": [ { "code": "00641139835", "type": "NDC" } ], "standard_charges": [ { "minimum": 14.5, "maximum": 48.36, "gross_charge": 51.45, "discounted_cash": 28.3, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.84, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.09, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.16, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.58, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.97, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.7, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.82, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.77, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 48.36, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.28, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.5, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.73, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.59, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.13, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.99, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 48.36, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.29, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.09, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.9, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.59, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.28, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.84, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.09, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CHLORTHALIDONE 25 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "51079005820", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CHOLECALCIFEROL 10 MCG (400 UNITS)/0.028ML PO LIQD", "drug_information": { "unit": "0.020000", "type": "UN" }, "code_information": [ { "code": "51228000006", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CHOLECALCIFEROL 125 MCG (5000 UT) PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "50268086615", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CHOLECALCIFEROL 25 MCG (1000 UT) PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "20555003300", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CHOLESTYRAMINE 4 G PO PACK", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "27241013436", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CHOLESTYRAMINE 5% IN KARAYA PASTE", "drug_information": { "unit": "120.000000", "type": "GR" }, "code_information": [ { "code": "P6076100012", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.41, "maximum": 4.71, "gross_charge": 5.01, "discounted_cash": 2.76, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.91, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.74, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.01, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.24, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.46, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.71, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.41, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.26, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.77, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.41, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.71, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.92, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.74, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.98, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.41, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.91, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.74, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CHOLINE FENOFIBRATE 45 MG PO CPDR", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "59651021690", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CHORIOGONADOTROPIN ALFA 250 MCG/0.5ML SC SOSY", "drug_information": { "unit": "0.500000", "type": "UN" }, "code_information": [ { "code": "44087115001", "type": "NDC" } ], "standard_charges": [ { "minimum": 209.27, "maximum": 1158.0, "gross_charge": 742.63, "discounted_cash": 408.45, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 430.73, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 405.48, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 644.6, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 216.11, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 356.46, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 444.84, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 444.09, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 698.07, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 653.51, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 209.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 631.24, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 556.97, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 261.63, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 504.99, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 698.07, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 581.48, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 405.48, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 590.39, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 556.97, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 653.51, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 430.73, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 405.48, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CHORIONIC GONADOTROPIN 10000 UNITS IM SOLR", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "00052031510", "type": "NDC" } ], "standard_charges": [ { "minimum": 103.68, "maximum": 345.84, "gross_charge": 367.92, "discounted_cash": 202.36, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 213.39, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 200.88, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 294.34, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 311.63, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 107.06, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 176.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 220.38, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 220.02, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 345.84, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 323.77, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.68, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 312.73, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 275.94, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 129.62, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 250.19, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 345.84, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 288.08, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 200.88, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 292.5, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 275.94, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 323.77, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 213.39, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 200.88, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CICLOPIROX 0.77 % EX GEL", "drug_information": { "unit": "30.000000", "type": "GR" }, "code_information": [ { "code": "00574206130", "type": "NDC" } ], "standard_charges": [ { "minimum": 41.19, "maximum": 137.38, "gross_charge": 146.15, "discounted_cash": 80.38, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 84.77, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 79.8, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 116.92, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 123.79, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.53, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 70.15, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.54, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 137.38, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 128.61, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.19, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 124.23, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 109.61, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 51.49, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 99.38, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 137.38, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 114.44, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 79.8, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 116.19, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 109.61, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 128.61, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 84.77, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 79.8, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CICLOPIROX 1 % EX SHAM", "drug_information": { "unit": "120.000000", "type": "UN" }, "code_information": [ { "code": "45802040109", "type": "NDC" } ], "standard_charges": [ { "minimum": 13.63, "maximum": 45.45, "gross_charge": 48.35, "discounted_cash": 26.59, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.04, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.4, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.68, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.95, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.07, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.21, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.91, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.45, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.55, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.63, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.1, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.26, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.03, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.88, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.45, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.86, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.4, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.44, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.26, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.55, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.04, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.4, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CICLOPIROX 8 % EX SOLN", "drug_information": { "unit": "6.600000", "type": "UN" }, "code_information": [ { "code": "45802014167", "type": "NDC" } ], "standard_charges": [ { "minimum": 15.32, "maximum": 51.09, "gross_charge": 54.35, "discounted_cash": 29.89, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.52, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.68, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.48, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.03, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.82, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.09, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.56, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.5, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 51.09, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.83, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.32, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.2, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.76, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.15, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.96, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 51.09, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.56, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.68, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.21, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.76, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.83, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.52, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.68, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CICLOPIROX OLAMINE 0.77 % EX CREA", "drug_information": { "unit": "15.000000", "type": "GR" }, "code_information": [ { "code": "68462029717", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.39, "maximum": 4.63, "gross_charge": 4.93, "discounted_cash": 2.71, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.86, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.69, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.94, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.18, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.43, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.37, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.95, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.95, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.63, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.34, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.39, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.19, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.7, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.74, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.35, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.63, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.86, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.69, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.92, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.7, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.34, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.86, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.69, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CIDOFOVIR 75 MG/ML IV SOLN", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "23155021631", "type": "NDC" } ], "standard_charges": [ { "minimum": 288.29, "maximum": 1873.01, "gross_charge": 1992.56, "discounted_cash": 1095.91, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1155.68, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 288.29, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1594.05, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1687.7, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 579.83, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 956.43, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1193.54, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 1191.55, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1873.01, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1753.45, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 561.5, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1693.68, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1494.42, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 701.98, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1354.94, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1873.01, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1560.17, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 389.19, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1584.09, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1494.42, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1753.45, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1155.68, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 288.29, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "CIDOFOVIR INTRAVITREAL INJ 20 MCG/0.1 ML", "drug_information": { "unit": "0.100000", "type": "UN" }, "code_information": [ { "code": "08252000162", "type": "NDC" } ], "standard_charges": [ { "minimum": 562.87, "maximum": 1877.56, "gross_charge": 1997.4, "discounted_cash": 1098.57, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.49, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1090.58, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1597.92, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1691.8, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 581.24, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 958.75, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1196.44, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 1194.45, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1877.56, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1757.71, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 562.87, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1697.79, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1498.05, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 703.68, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1358.23, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1877.56, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1563.96, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1090.58, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1587.93, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1498.05, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1757.71, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.49, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1090.58, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Ciliary transsleral therapy", "code_information": [ { "code": "66710", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1719.62, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1273.8, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 4441.63, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 8059.4, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1719.62, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 8059.4, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CILOSTAZOL 100 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "50268017715", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CILOSTAZOL 50 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "50268017615", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CINACALCET 5 MG/ML ORAL SUSPENSION (PTL)", "drug_information": { "unit": "6.000000", "type": "UN" }, "code_information": [ { "code": "08252000026", "type": "NDC" } ], "standard_charges": [ { "minimum": 13.14, "maximum": 43.83, "gross_charge": 46.63, "discounted_cash": 25.65, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.05, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.46, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.3, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.57, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.38, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.93, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.88, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.83, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.03, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.14, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.64, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.97, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.43, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.71, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.83, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.51, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.46, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.07, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.97, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.03, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.05, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.46, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CINACALCET HCL 30 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "50268015312", "type": "NDC" } ], "standard_charges": [ { "minimum": 9.52, "maximum": 1158.0, "gross_charge": 33.8, "discounted_cash": 18.59, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.45, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.34, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.84, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.22, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.25, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.21, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.77, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.74, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.52, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.73, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.35, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.91, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.98, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.77, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.47, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.45, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.87, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.35, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.74, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.45, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CINACALCET HCL 60 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "1671407901", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 1158.0, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.47, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CINACALCET HCL 90 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "55513007530", "type": "NDC" } ], "standard_charges": [ { "minimum": 43.0, "maximum": 1158.0, "gross_charge": 152.59, "discounted_cash": 83.92, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.5, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 83.31, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 132.45, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 44.4, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 73.24, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 91.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 91.25, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 143.43, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 134.28, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 129.7, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 114.44, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 53.76, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.76, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 143.43, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 119.48, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 83.31, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 121.31, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 114.44, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 134.28, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.5, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 83.31, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CIPROFLOXACIN 2 MG/ML IVPB-RTU (PEDS)", "drug_information": { "unit": "100.000000", "type": "UN" }, "code_information": [ { "code": "00409230024", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CIPROFLOXACIN 2 MG/ML SYR-RTU (PEDS)", "drug_information": { "unit": "100.000000", "type": "UN" }, "code_information": [ { "code": "00409230024_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CIPROFLOXACIN 200 MG/100 ML RTU", "drug_information": { "unit": "100.000000", "type": "UN" }, "code_information": [ { "code": "00409230024_3", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CIPROFLOXACIN 250 MG/5ML (5%) PO SUSR", "drug_information": { "unit": "100.000000", "type": "UN" }, "code_information": [ { "code": "50419077701", "type": "NDC" } ], "standard_charges": [ { "minimum": 83.21, "maximum": 277.56, "gross_charge": 295.28, "discounted_cash": 162.4, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 171.26, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 161.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 236.22, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 250.1, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 85.93, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 141.73, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 176.87, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 176.58, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 277.56, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 259.85, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 83.21, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 250.99, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 221.46, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 104.03, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 200.79, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 277.56, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 231.2, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 161.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 234.75, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 221.46, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 259.85, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 171.26, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 161.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CIPROFLOXACIN 400 MG/200 ML RTU", "drug_information": { "unit": "200.000000", "type": "UN" }, "code_information": [ { "code": "25021019287", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CIPROFLOXACIN 500 MG/5ML (10%) PO SUSR", "drug_information": { "unit": "100.000000", "type": "UN" }, "code_information": [ { "code": "50419077301", "type": "NDC" } ], "standard_charges": [ { "minimum": 97.19, "maximum": 324.21, "gross_charge": 344.9, "discounted_cash": 189.7, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 200.04, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 188.32, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 275.92, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 292.13, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 100.37, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 165.55, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 206.6, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 206.25, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 324.21, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 303.51, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 97.19, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 293.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 258.68, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 121.51, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 234.53, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 324.21, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 270.06, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 188.32, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 274.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 258.68, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 303.51, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 200.04, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 188.32, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CIPROFLOXACIN HCL 0.3 % INTRATRACHEA SOLN", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "61314065605", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CIPROFLOXACIN HCL 0.3 % OP SOLN", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "61314065605_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CIPROFLOXACIN HCL 0.3 % OP SOLN (OTIC USE)", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "61314065605_3", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CIPROFLOXACIN HCL 0.3 % OP SOLN 2.5 ML BOTTLE (BULK CHARGE)", "drug_information": { "unit": "2.500000", "type": "UN" }, "code_information": [ { "code": "61314065625", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CIPROFLOXACIN HCL 250 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "1625251401", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CIPROFLOXACIN HCL 500 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00904724361", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CIPROFLOXACIN HCL 750 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "1625251605", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CIPROFLOXACIN-DEXAMETHASONE 0.3-0.1 % OT SUSP", "drug_information": { "unit": "7.500000", "type": "UN" }, "code_information": [ { "code": "72485062513", "type": "NDC" } ], "standard_charges": [ { "minimum": 57.04, "maximum": 190.28, "gross_charge": 202.43, "discounted_cash": 111.34, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 117.41, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 110.53, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 161.94, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 171.46, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 58.91, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 97.17, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 121.26, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 121.05, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 190.28, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 178.14, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 57.04, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 172.07, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 151.82, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 71.32, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 137.65, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 190.28, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 158.5, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 110.53, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 160.93, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 151.82, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 178.14, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 117.41, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 110.53, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Circum 28 days or older", "code_information": [ { "code": "54161", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1509.96, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1118.49, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 7877.59, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 14294.01, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1509.96, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 14294.01, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CISATRACURIUM BESYLATE (PF) 10 MG/5ML IV SOLN", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "71288071206", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 1158.0, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.72, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CISATRACURIUM BESYLATE (PF) 200 MG/20ML IV SOLN", "drug_information": { "unit": "20.000000", "type": "UN" }, "code_information": [ { "code": "71288071321", "type": "NDC" } ], "standard_charges": [ { "minimum": 24.89, "maximum": 1158.0, "gross_charge": 88.31, "discounted_cash": 48.57, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 51.22, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 48.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 76.65, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.7, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.39, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.9, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.81, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 83.01, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 77.71, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.89, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.06, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 66.23, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.11, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.05, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 83.01, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 69.15, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 48.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 70.21, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 66.23, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 77.71, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 51.22, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 48.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CISATRACURIUM BESYLATE 20 MG/10ML IV SOLN", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "71288071411", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 1158.0, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.72, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CISPLATIN 100 MG/100ML IV SOLN", "drug_information": { "unit": "100.000000", "type": "UN" }, "code_information": [ { "code": "72266025301", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CISPLATIN 200 MG/200ML IV SOLN", "drug_information": { "unit": "200.000000", "type": "UN" }, "code_information": [ { "code": "44567051101", "type": "NDC" } ], "standard_charges": [ { "minimum": 28.72, "maximum": 95.79, "gross_charge": 101.9, "discounted_cash": 56.05, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.1, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.64, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 81.52, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.31, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.65, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 48.91, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.04, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.94, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 95.79, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 89.67, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.72, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.62, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 76.43, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.9, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 69.29, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 95.79, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 79.79, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.64, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 81.01, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 76.43, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 89.67, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.1, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.64, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CISPLATIN 50 MG/50ML IV SOLN", "drug_information": { "unit": "50.000000", "type": "UN" }, "code_information": [ { "code": "16729028811", "type": "NDC" } ], "standard_charges": [ { "minimum": 12.44, "maximum": 41.5, "gross_charge": 44.15, "discounted_cash": 24.28, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.61, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.11, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.32, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.85, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.19, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.45, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.5, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.85, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.44, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.53, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.11, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.55, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.02, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.5, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.57, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.11, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.1, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.11, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.85, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.61, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.11, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CISPLATIN CHEMOEMBOLIZATION (1 MG/ML)", "drug_information": { "unit": "50.000000", "type": "UN" }, "code_information": [ { "code": "00703574711", "type": "NDC" } ], "standard_charges": [ { "minimum": 32.2, "maximum": 107.42, "gross_charge": 114.28, "discounted_cash": 62.85, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 66.28, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 62.4, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 91.42, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.26, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.85, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 68.45, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 68.34, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 107.42, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 100.57, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.2, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 97.14, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 85.71, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.26, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 77.71, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 107.42, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 89.48, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 62.4, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 90.85, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 85.71, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 100.57, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 66.28, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 62.4, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CISPLATIN FOR CHEMOPERFUSION", "drug_information": { "unit": "50.000000", "type": "UN" }, "code_information": [ { "code": "00703574711_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 32.2, "maximum": 107.42, "gross_charge": 114.28, "discounted_cash": 62.85, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 66.28, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 62.4, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 91.42, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.26, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.85, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 68.45, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 68.34, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 107.42, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 100.57, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.2, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 97.14, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 85.71, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.26, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 77.71, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 107.42, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 89.48, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 62.4, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 90.85, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 85.71, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 100.57, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 66.28, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 62.4, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CITALOPRAM HYDROBROMIDE 10 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00904608461", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CITALOPRAM HYDROBROMIDE 10 MG/5ML PO SOLN", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "31722056424", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CITALOPRAM HYDROBROMIDE 20 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00904608561", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CITALOPRAM HYDROBROMIDE 40 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "R1366801101", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CITRANATAL 90 DHA 90-1 & 300 MG PO MISC", "drug_information": { "unit": "2.000000", "type": "UN" }, "code_information": [ { "code": "00178082130", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.8, "maximum": 9.33, "gross_charge": 9.93, "discounted_cash": 5.46, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.76, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.42, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.94, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.41, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.89, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.77, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.95, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.94, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.33, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.74, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.8, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.44, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.45, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.5, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.75, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.33, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.78, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.42, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.89, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.45, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.74, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.76, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.42, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CITRATE OF MAGNESIA PO SOLN", "drug_information": { "unit": "296.000000", "type": "UN" }, "code_information": [ { "code": "69452039098", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CITRIC ACID-SODIUM CITRATE 334-500 MG/5 ML PO SOLN (NICU)", "drug_information": { "unit": "30.000000", "type": "UN" }, "code_information": [ { "code": "00121119000", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.61, "maximum": 8.71, "gross_charge": 9.27, "discounted_cash": 5.1, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.38, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.42, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.85, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.7, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.45, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.55, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.54, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.71, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.16, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.61, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.95, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.27, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.3, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.71, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.26, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.37, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.95, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.16, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.38, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CITRUS CALCIUM/VITAMIN D 200-6.25 MG-MCG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00536322301", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CLADRIBINE 10 MG/10ML IV SOLN", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "00143987101", "type": "NDC" } ], "standard_charges": [ { "minimum": 7.78, "maximum": 183.89, "gross_charge": 195.63, "discounted_cash": 107.6, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 113.47, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.78, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 156.5, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 165.7, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 56.93, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.9, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 117.18, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 116.99, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 183.89, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 172.15, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 166.29, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 146.72, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 68.92, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 133.03, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 183.89, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 153.18, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.5, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 155.53, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 146.72, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 172.15, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 113.47, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.78, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "CLARITHROMYCIN 250 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "50268017815", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CLARITHROMYCIN 250 MG/5ML PO SUSR", "drug_information": { "unit": "50.000000", "type": "UN" }, "code_information": [ { "code": "00781602352", "type": "NDC" } ], "standard_charges": [ { "minimum": 42.79, "maximum": 142.72, "gross_charge": 151.83, "discounted_cash": 83.51, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.06, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.9, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 121.46, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 128.6, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 44.18, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 72.88, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 90.95, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 90.79, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 142.72, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 133.61, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.79, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 129.06, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 113.87, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 53.49, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.24, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 142.72, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 118.88, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.9, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 120.7, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 113.87, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 133.61, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.06, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.9, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CLARITHROMYCIN 500 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687043521", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Clean out mastoid cavity", "code_information": [ { "code": "69222", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 375.37, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 278.05, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 9974.56, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 18106.2, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 375.37, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 18106.2, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Clear outer ear canal", "code_information": [ { "code": "69205", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1194.28, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 884.65, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 3397.6, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 6165.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1194.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 6165.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Clearance of tear duct", "code_information": [ { "code": "68530", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 220.34, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 163.22, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 6114.58, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 11095.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 220.34, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 11095.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CLEVIDIPINE 25 MG/50ML IV EMUL", "drug_information": { "unit": "50.000000", "type": "UN" }, "code_information": [ { "code": "10122061010_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CLEVIDIPINE 25 MG/50ML IV EMUL|DISCARDED DRUG NOT ADMINISTERED", "drug_information": { "unit": "50.000000", "type": "UN" }, "code_information": [ { "code": "10122061010", "type": "NDC" } ], "standard_charges": [ { "minimum": 21.4, "maximum": 71.39, "gross_charge": 75.95, "discounted_cash": 41.77, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 44.05, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.47, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.76, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 64.33, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.1, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.46, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.49, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.42, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 71.39, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 66.84, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.4, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 64.56, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 56.96, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.76, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 51.65, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 71.39, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.47, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.47, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.38, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 56.96, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 66.84, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 44.05, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.47, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CLEVIDIPINE 50 MG/100ML IV EMUL", "drug_information": { "unit": "100.000000", "type": "UN" }, "code_information": [ { "code": "10122061110", "type": "NDC" } ], "standard_charges": [ { "minimum": 42.8, "maximum": 142.78, "gross_charge": 151.89, "discounted_cash": 83.54, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.1, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.93, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 121.51, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 128.65, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 44.2, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 72.91, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 90.98, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 90.83, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 142.78, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 133.66, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.8, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 129.11, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 113.92, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 53.51, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.29, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 142.78, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 118.93, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.93, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 120.75, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 113.92, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 133.66, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.1, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.93, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CLINDAMYCIN 12 MG/ML SYR-RTU D5W (PEDS)", "drug_information": { "unit": "50.000000", "type": "UN" }, "code_information": [ { "code": "00338361224_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CLINDAMYCIN 12 MG/ML SYR-RTU NS (PEDS)", "drug_information": { "unit": "50.000000", "type": "UN" }, "code_information": [ { "code": "00338954924_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CLINDAMYCIN 18 MG/ML SYR-RTU (NICU)", "drug_information": { "unit": "50.000000", "type": "UN" }, "code_information": [ { "code": "00781329009_4", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CLINDAMYCIN 18 MG/ML SYR-RTU (NICU)|DISCARDED DRUG NOT ADMINISTERED", "drug_information": { "unit": "50.000000", "type": "UN" }, "code_information": [ { "code": "00781329009_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 6.03, "maximum": 20.12, "gross_charge": 21.4, "discounted_cash": 11.77, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.41, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.68, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.12, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.13, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.23, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.27, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.82, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.8, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.12, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.83, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.03, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.19, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.05, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.54, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.55, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.12, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.76, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.68, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.01, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.05, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.83, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.41, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.68, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CLINDAMYCIN 18 MG/ML SYR-RTU D5W (PEDS)", "drug_information": { "unit": "50.000000", "type": "UN" }, "code_information": [ { "code": "00781329009_5", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CLINDAMYCIN 18 MG/ML SYR-RTU D5W (PEDS)|DISCARDED DRUG NOT ADMINISTERED", "drug_information": { "unit": "50.000000", "type": "UN" }, "code_information": [ { "code": "00781329009_3", "type": "NDC" } ], "standard_charges": [ { "minimum": 6.03, "maximum": 20.12, "gross_charge": 21.4, "discounted_cash": 11.77, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.41, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.68, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.12, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.13, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.23, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.27, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.82, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.8, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.12, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.83, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.03, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.19, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.05, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.54, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.55, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.12, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.76, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.68, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.01, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.05, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.83, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.41, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.68, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CLINDAMYCIN 18 MG/ML SYR-RTU NS (PEDS)", "drug_information": { "unit": "50.000000", "type": "UN" }, "code_information": [ { "code": "00338955324_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CLINDAMYCIN 600 MG/50 ML IN D5W RTU", "drug_information": { "unit": "50.000000", "type": "UN" }, "code_information": [ { "code": "00338361224_3", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CLINDAMYCIN 600 MG/50 ML IN D5W RTU|DISCARDED DRUG NOT ADMINISTERED", "drug_information": { "unit": "50.000000", "type": "UN" }, "code_information": [ { "code": "00338361224", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.32, "maximum": 4.41, "gross_charge": 4.69, "discounted_cash": 2.58, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.56, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.75, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.97, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.36, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.25, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.81, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.8, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.41, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.13, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.32, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.99, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.65, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.19, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.41, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.67, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.56, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.73, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.13, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.56, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CLINDAMYCIN 600 MG/50 ML IN NS RTU", "drug_information": { "unit": "50.000000", "type": "UN" }, "code_information": [ { "code": "00338954924_3", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CLINDAMYCIN 600 MG/50 ML IN NS RTU|DISCARDED DRUG NOT ADMINISTERED", "drug_information": { "unit": "50.000000", "type": "UN" }, "code_information": [ { "code": "00338954924", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.32, "maximum": 4.41, "gross_charge": 4.69, "discounted_cash": 2.58, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.56, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.75, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.97, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.36, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.25, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.81, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.8, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.41, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.13, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.32, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.99, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.65, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.19, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.41, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.67, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.56, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.73, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.13, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.56, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CLINDAMYCIN 900 MG/50 ML RTU", "drug_information": { "unit": "50.000000", "type": "UN" }, "code_information": [ { "code": "00781329009_6", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CLINDAMYCIN 900 MG/50 ML RTU|DISCARDED DRUG NOT ADMINISTERED", "drug_information": { "unit": "50.000000", "type": "UN" }, "code_information": [ { "code": "00781329009", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.41, "maximum": 8.05, "gross_charge": 8.56, "discounted_cash": 4.71, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.96, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.67, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.85, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.25, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.49, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.11, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.13, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.12, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.05, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.53, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.41, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.28, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.42, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.02, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.82, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.05, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.7, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.67, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.81, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.42, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.53, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.96, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.67, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CLINDAMYCIN HCL 150 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00904595961", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CLINDAMYCIN INTRAVITREAL INJ (1MG/0.05ML)", "drug_information": { "unit": "0.050000", "type": "UN" }, "code_information": [ { "code": "C8252000083", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CLINDAMYCIN INTRAVITREAL INJ (1MG/0.1ML)", "drug_information": { "unit": "0.100000", "type": "UN" }, "code_information": [ { "code": "C2502111502_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CLINDAMYCIN INTRAVITREAL INJ (1MG/0.1ML)|DISCARDED DRUG NOT ADMINISTERED", "drug_information": { "unit": "0.100000", "type": "UN" }, "code_information": [ { "code": "C2502111502", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.1, "maximum": 0.32, "gross_charge": 0.34, "discounted_cash": 0.19, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.19, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.27, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.29, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.1, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.16, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.2, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.2, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.32, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.3, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.1, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.29, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.26, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.12, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.23, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.32, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.27, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.19, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.27, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.26, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.3, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.19, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CLINDAMYCIN PALMITATE HCL 75 MG/5ML PO SOLR", "drug_information": { "unit": "100.000000", "type": "UN" }, "code_information": [ { "code": "65862059602", "type": "NDC" } ], "standard_charges": [ { "minimum": 9.91, "maximum": 33.04, "gross_charge": 35.15, "discounted_cash": 19.33, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.39, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.19, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.12, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.77, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.23, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.87, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.05, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.02, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.04, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.93, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.91, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.36, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.38, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.9, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.04, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.52, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.19, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.94, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.36, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.93, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.39, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.19, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CLINDAMYCIN PHOS-BENZOYL PEROX 1-5 % EX GEL", "drug_information": { "unit": "50.000000", "type": "GR" }, "code_information": [ { "code": "00378868854", "type": "NDC" } ], "standard_charges": [ { "minimum": 95.71, "maximum": 319.27, "gross_charge": 339.65, "discounted_cash": 186.81, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 197.0, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 185.45, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 271.72, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 287.68, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 98.84, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 163.03, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 203.45, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 203.11, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 319.27, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 298.89, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 95.71, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 288.7, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 254.74, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 119.66, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 230.96, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 319.27, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 265.95, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 185.45, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 270.02, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 254.74, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 298.89, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 197.0, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 185.45, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CLINDAMYCIN PHOS-BENZOYL PEROX 1.2-2.5 % EX GEL", "drug_information": { "unit": "50.000000", "type": "GR" }, "code_information": [ { "code": "13548013250", "type": "NDC" } ], "standard_charges": [ { "minimum": 336.59, "maximum": 1122.76, "gross_charge": 1194.43, "discounted_cash": 656.94, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 692.77, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 652.16, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 955.54, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1011.68, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 347.58, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 573.33, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 715.46, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 714.27, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1122.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1051.1, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 336.59, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1015.27, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 895.82, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 420.8, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 812.21, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1122.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 935.24, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 652.16, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 949.57, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 895.82, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1051.1, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 692.77, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 652.16, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CLINDAMYCIN PHOSPHATE 1 % EX GEL", "drug_information": { "unit": "30.000000", "type": "GR" }, "code_information": [ { "code": "59762374301", "type": "NDC" } ], "standard_charges": [ { "minimum": 19.11, "maximum": 63.73, "gross_charge": 67.8, "discounted_cash": 37.29, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.02, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.24, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 57.43, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.73, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.54, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.61, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.54, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.73, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.66, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.11, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 57.63, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.85, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.89, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.1, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.73, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 53.09, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.02, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 53.9, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.85, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.66, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.02, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CLINDAMYCIN PHOSPHATE 1 % EX LOTN", "drug_information": { "unit": "60.000000", "type": "UN" }, "code_information": [ { "code": "59762374401", "type": "NDC" } ], "standard_charges": [ { "minimum": 47.34, "maximum": 157.92, "gross_charge": 168.0, "discounted_cash": 92.4, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 97.44, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 91.73, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 134.4, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 142.3, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 48.89, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 80.64, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 100.63, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 100.46, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 157.92, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 147.84, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.34, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 142.8, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 126.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.19, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 114.24, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 157.92, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 131.54, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 91.73, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 133.56, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 126.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 147.84, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 97.44, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 91.73, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CLINDAMYCIN PHOSPHATE 1 % EX SOLN", "drug_information": { "unit": "30.000000", "type": "UN" }, "code_information": [ { "code": "45802056201", "type": "NDC" } ], "standard_charges": [ { "minimum": 3.0, "maximum": 10.01, "gross_charge": 10.65, "discounted_cash": 5.86, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.18, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.81, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.52, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.02, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.1, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.11, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.38, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.37, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.01, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.37, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.05, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.99, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.24, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.01, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.34, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.81, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.47, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.99, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.37, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.18, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.81, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CLINDAMYCIN PHOSPHATE 1 % EX SWAB", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "45802026337", "type": "NDC" } ], "standard_charges": [ { "minimum": 14.08, "maximum": 46.95, "gross_charge": 49.95, "discounted_cash": 27.47, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.97, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.27, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.96, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.31, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.54, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.98, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.87, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.95, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.96, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.08, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.46, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.46, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.6, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.97, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.95, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.11, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.27, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.71, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.46, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.96, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.97, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.27, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CLINDAMYCIN PHOSPHATE 2 % VA CREA", "drug_information": { "unit": "40.000000", "type": "GR" }, "code_information": [ { "code": "00168027740", "type": "NDC" } ], "standard_charges": [ { "minimum": 41.26, "maximum": 137.62, "gross_charge": 146.4, "discounted_cash": 80.52, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 84.91, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 79.93, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 117.12, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 124.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.6, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 70.27, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.69, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.55, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 137.62, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 128.83, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.26, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 124.44, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 109.8, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 51.58, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 99.55, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 137.62, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 114.63, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 79.93, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 116.39, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 109.8, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 128.83, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 84.91, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 79.93, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CLINDAMYCIN PHOSPHATE 300 MG/2ML IJ SOLN", "drug_information": { "unit": "2.000000", "type": "UN" }, "code_information": [ { "code": "00009087026_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CLINDAMYCIN PHOSPHATE 300 MG/2ML IJ SOLN|DISCARDED DRUG NOT ADMINISTERED", "drug_information": { "unit": "2.000000", "type": "UN" }, "code_information": [ { "code": "00009087026", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.07, "maximum": 3.56, "gross_charge": 3.79, "discounted_cash": 2.08, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.07, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.03, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.21, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.1, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.82, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.27, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.27, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.56, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.34, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.07, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.22, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.84, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.34, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.58, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.56, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.97, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.07, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.01, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.84, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.34, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.07, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CLINDAMYCIN PHOSPHATE 600 MG/4ML IJ SOLN", "drug_information": { "unit": "4.000000", "type": "UN" }, "code_information": [ { "code": "00009077526_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CLINDAMYCIN PHOSPHATE 600 MG/4ML IJ SOLN|DISCARDED DRUG NOT ADMINISTERED", "drug_information": { "unit": "4.000000", "type": "UN" }, "code_information": [ { "code": "00009077526", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.31, "maximum": 4.38, "gross_charge": 4.66, "discounted_cash": 2.56, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.7, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.54, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.73, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.95, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.36, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.24, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.79, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.79, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.38, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.1, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.31, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.96, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.64, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.17, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.38, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.65, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.54, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.7, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.1, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.7, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.54, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CLINDAMYCIN PHOSPHATE 900 MG/6ML IJ SOLN", "drug_information": { "unit": "6.000000", "type": "UN" }, "code_information": [ { "code": "25021011506_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CLINDAMYCIN PHOSPHATE 900 MG/6ML IJ SOLN|DISCARDED DRUG NOT ADMINISTERED", "drug_information": { "unit": "6.000000", "type": "UN" }, "code_information": [ { "code": "25021011506", "type": "NDC" } ], "standard_charges": [ { "minimum": 3.03, "maximum": 10.11, "gross_charge": 10.76, "discounted_cash": 5.92, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.24, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.87, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.61, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.11, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.16, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.45, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.43, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.11, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.47, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.03, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.15, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.07, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.79, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.32, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.11, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.43, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.87, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.55, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.07, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.47, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.24, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.87, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CLINDAMYCIN PHOSPHATE IN NACL 900-0.9 MG/50ML-% IV SOLN", "drug_information": { "unit": "50.000000", "type": "UN" }, "code_information": [ { "code": "00338955324_3", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CLINDAMYCIN PHOSPHATE IN NACL 900-0.9 MG/50ML-% IV SOLN|DISCARDED DRUG NOT ADMINISTERED", "drug_information": { "unit": "50.000000", "type": "UN" }, "code_information": [ { "code": "00338955324", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.63, "maximum": 5.45, "gross_charge": 5.8, "discounted_cash": 3.19, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.36, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.17, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.91, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.69, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.78, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.47, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.47, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.45, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.1, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.63, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.93, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.35, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.04, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.94, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.45, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.54, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.17, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.61, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.35, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.1, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.36, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.17, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CLOBAZAM 10 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687042321", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.25, "maximum": 7.52, "gross_charge": 8.0, "discounted_cash": 4.4, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.4, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.78, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.33, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.84, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.79, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.25, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.8, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.82, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.44, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.26, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.36, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CLOBAZAM 2.5 MG/ML PO SUSP", "drug_information": { "unit": "120.000000", "type": "UN" }, "code_information": [ { "code": "59651040112", "type": "NDC" } ], "standard_charges": [ { "minimum": 13.84, "maximum": 46.15, "gross_charge": 49.1, "discounted_cash": 27.01, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.48, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.81, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.28, "standard_charge_percentage": 80.0, "methodology": 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60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.15, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.21, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.84, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.74, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": 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"percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.81, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CLOBETASOL PROPIONATE 0.05 % EX CREA", "drug_information": { "unit": "15.000000", "type": "GR" }, "code_information": [ { "code": "51672125801", "type": "NDC" } ], "standard_charges": [ { "minimum": 6.38, "maximum": 21.29, "gross_charge": 22.65, "discounted_cash": 12.46, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.14, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.12, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.18, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.59, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.87, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.57, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.54, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.29, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.93, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.38, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.25, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.99, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.98, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.4, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.29, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.73, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.01, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.99, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.93, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.14, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CLOBETASOL PROPIONATE 0.05 % EX GEL", "drug_information": { "unit": "60.000000", "type": "GR" }, "code_information": [ { "code": "51672129403", "type": "NDC" } ], "standard_charges": [ { "minimum": 50.82, "maximum": 169.53, "gross_charge": 180.35, "discounted_cash": 99.19, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 104.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 98.47, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 144.28, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 152.76, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.48, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.57, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 108.03, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 107.85, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 169.53, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 158.71, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.82, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 153.3, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 135.26, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.54, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 122.64, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 169.53, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 141.21, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 98.47, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 143.38, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 135.26, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 158.71, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 104.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 98.47, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CLOBETASOL PROPIONATE 0.05 % EX LIQD", "drug_information": { "unit": "125.000000", "type": "UN" }, "code_information": [ { "code": "00299384904", "type": "NDC" } ], "standard_charges": [ { "minimum": 584.9, "maximum": 1951.05, "gross_charge": 2075.58, "discounted_cash": 1141.57, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1203.84, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1133.27, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1660.46, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1758.02, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 603.99, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 996.28, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1243.27, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 1241.2, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1951.05, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1826.51, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 584.9, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1764.24, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1556.69, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 731.23, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1411.39, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1951.05, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1625.18, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1133.27, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1650.09, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1556.69, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1826.51, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1203.84, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1133.27, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CLOBETASOL PROPIONATE 0.05 % EX OINT", "drug_information": { "unit": "15.000000", "type": "GR" }, "code_information": [ { "code": "42291007715", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.67, "maximum": 5.57, "gross_charge": 5.93, "discounted_cash": 3.26, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.44, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.24, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { 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"plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.55, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.1, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 76.17, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.45, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 44.24, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 64.42, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.77, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 71.31, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.0, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 44.24, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CLOFARABINE 1 MG/ML IV SOLN", "drug_information": { "unit": "20.000000", "type": "UN" }, "code_information": [ { "code": "60505616600", "type": "NDC" } ], "standard_charges": [ { "minimum": 7.85, "maximum": 4840.95, "gross_charge": 5149.95, "discounted_cash": 2832.47, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2986.97, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.85, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4119.96, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4362.01, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1498.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2471.98, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3084.82, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 3079.67, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4840.95, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4531.96, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1451.26, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4377.46, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3862.46, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1814.33, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3501.97, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4840.95, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", 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"additional_payer_notes": "N/A", "standard_charge_dollar": 2986.97, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.85, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "CLOMIPHENE CITRATE 50 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00713088509", "type": "NDC" } ], "standard_charges": [ { "minimum": 5.02, "maximum": 16.74, "gross_charge": 17.81, "discounted_cash": 9.8, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.33, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.72, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.25, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.09, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.18, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.55, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.67, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.65, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.74, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.67, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.02, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.14, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.36, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.27, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.11, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.74, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.95, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.72, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.16, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.36, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.67, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.33, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.72, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CLOMIPRAMINE HCL 25 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68084079025", "type": "NDC" } ], "standard_charges": [ { "minimum": 5.01, "maximum": 16.71, "gross_charge": 17.78, "discounted_cash": 9.78, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.31, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.71, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.22, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.06, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.17, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.53, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.65, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.63, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.71, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.65, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.01, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.11, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.34, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.26, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.09, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.71, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.92, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.71, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.14, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.34, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.65, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.31, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.71, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CLOMIPRAMINE HCL 50 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68084081825", "type": "NDC" } ], "standard_charges": [ { "minimum": 5.86, "maximum": 19.56, "gross_charge": 20.81, "discounted_cash": 11.45, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.07, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.36, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.65, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.63, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.06, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.99, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.47, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.44, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.56, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.31, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.86, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.69, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.61, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.33, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.15, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.56, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.29, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.36, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.54, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.61, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.31, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.07, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.36, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CLOMIPRAMINE HCL 75 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "27241021230", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CLONAZEPAM 0.125 MG PO TBDP", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "49884030602", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.25, "maximum": 7.52, "gross_charge": 8.0, "discounted_cash": 4.4, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.4, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.78, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.33, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.84, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.79, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.25, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.8, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.82, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.44, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.26, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.36, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CLONAZEPAM 0.1MG/ML ORAL SUSPENSION", "drug_information": { "unit": "100.000000", "type": "UN" }, "code_information": [ { "code": "P0228300411", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.75, "maximum": 9.17, "gross_charge": 9.75, "discounted_cash": 5.36, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.66, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.32, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.26, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.84, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.68, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.84, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.83, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.17, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.58, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.75, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.29, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.31, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.43, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.63, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.17, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.63, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.32, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.75, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.31, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.58, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.66, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.32, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CLONAZEPAM 0.25 MG PO TBDP", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "49884030702", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.25, "maximum": 7.52, "gross_charge": 8.0, "discounted_cash": 4.4, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.4, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.78, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.33, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.84, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.79, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.25, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.8, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.82, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.44, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.26, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.36, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CLONAZEPAM 0.5 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "1671446902", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.25, "maximum": 7.52, "gross_charge": 8.0, "discounted_cash": 4.4, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.4, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.78, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.33, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.84, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.79, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.25, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.8, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.82, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.44, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.26, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.36, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CLONAZEPAM 1 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00904772861", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.25, "maximum": 7.52, "gross_charge": 8.0, "discounted_cash": 4.4, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.4, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.78, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.33, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.84, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.79, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.25, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.8, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.82, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.44, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.26, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.36, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CLONAZEPAM 1 MG PO TBDP", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "49884030902", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.25, "maximum": 7.52, "gross_charge": 8.0, "discounted_cash": 4.4, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.4, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.78, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.33, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.84, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.79, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.25, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.8, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.82, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.44, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.26, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.36, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CLONAZEPAM 2 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "R0093321301", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.25, "maximum": 7.52, "gross_charge": 8.0, "discounted_cash": 4.4, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.4, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.78, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.33, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.84, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.79, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.25, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.8, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.82, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.44, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.26, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.36, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CLONIDINE 0.1 MG/24HR TD PTWK", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00591350854", "type": "NDC" } ], "standard_charges": [ { "minimum": 4.46, "maximum": 14.86, "gross_charge": 15.81, "discounted_cash": 8.7, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.17, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.63, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.65, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.6, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.59, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.47, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.45, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.86, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.91, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.46, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.44, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.86, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.57, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.75, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.86, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.38, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.63, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.57, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.86, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.91, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.17, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.63, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CLONIDINE 0.2 MG/24HR TD PTWK", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00591350954", "type": "NDC" } ], "standard_charges": [ { "minimum": 9.71, "maximum": 32.4, "gross_charge": 34.47, "discounted_cash": 18.96, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.99, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.82, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.58, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.2, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.03, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.55, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.65, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.61, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.33, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.71, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.3, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.85, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.14, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.44, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.99, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.82, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.4, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.85, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.33, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.99, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.82, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CLONIDINE 0.3 MG/24HR TD PTWK", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00591351054", "type": "NDC" } ], "standard_charges": [ { "minimum": 14.26, "maximum": 47.55, "gross_charge": 50.59, "discounted_cash": 27.82, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.34, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.62, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.47, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.85, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.72, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.28, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.3, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.25, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.55, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 44.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.26, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.94, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.82, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.4, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.55, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.61, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.62, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.22, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.94, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 44.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.34, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.62, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CLONIDINE 20 MCG/ML SUSPENSION", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "00000000026", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CLONIDINE HCL (ANALGESIA) 100 MCG/ML EP SOLN", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "39822200001", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.01, "maximum": 36.74, "gross_charge": 39.08, "discounted_cash": 21.49, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.67, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.34, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.26, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.1, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.37, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.76, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.41, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.37, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.74, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.39, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.01, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.22, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.31, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.77, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.57, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.74, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.6, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.34, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.07, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.31, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.39, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.67, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.34, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CLONIDINE HCL (ANALGESIA) 500 MCG/ML EP SOLN", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "39822201001", "type": "NDC" } ], "standard_charges": [ { "minimum": 75.04, "maximum": 250.3, "gross_charge": 266.28, "discounted_cash": 146.45, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 154.44, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 145.39, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 213.02, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 225.54, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 77.49, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 127.81, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 159.5, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 159.24, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 250.3, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 234.33, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.04, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 226.34, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 199.71, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.81, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 181.07, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 250.3, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 208.5, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 145.39, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 211.69, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 199.71, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 234.33, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 154.44, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 145.39, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CLONIDINE HCL 0.1 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687011301", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CLONIDINE HCL 0.2 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687012401", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CLONIDINE HCL 0.3 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "1013571001", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CLONIDINE HCL ER 0.1 MG PO TB12", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687046221", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.38, "maximum": 7.93, "gross_charge": 8.44, "discounted_cash": 4.64, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.9, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.61, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.75, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.15, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.46, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.05, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.06, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.05, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.93, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.43, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.38, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.33, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.97, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.74, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.93, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.61, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.61, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.71, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.33, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.43, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.9, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.61, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CLOPIDOGREL BISULFATE 300 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68084075219", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.7, "maximum": 9.01, "gross_charge": 9.58, "discounted_cash": 5.27, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.56, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.23, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.66, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.11, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.79, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.74, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.73, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.01, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.43, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.7, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.14, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.19, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.38, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.51, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.01, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.5, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.23, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.62, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.19, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.43, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.56, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.23, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CLOPIDOGREL BISULFATE 5 MG/ML SUSPENSION", "drug_information": { "unit": "15.000000", "type": "UN" }, "code_information": [ { "code": "P6365311711", "type": "NDC" } ], "standard_charges": [ { "minimum": 4.24, "maximum": 14.13, "gross_charge": 15.03, "discounted_cash": 8.27, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.72, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.21, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.02, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.73, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.21, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.0, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.99, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.13, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.23, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.24, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.78, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.3, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.22, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.13, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.77, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.21, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.95, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.23, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.72, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.21, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CLOPIDOGREL BISULFATE 75 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68084053601", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CLORAZEPATE DIPOTASSIUM 15 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "R0378007001", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.25, "maximum": 7.52, "gross_charge": 8.0, "discounted_cash": 4.4, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.4, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.78, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.33, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.84, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.79, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.25, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.8, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.82, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.44, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.26, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.36, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CLORAZEPATE DIPOTASSIUM 3.75 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "1310728201", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.25, "maximum": 7.52, "gross_charge": 8.0, "discounted_cash": 4.4, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.4, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.78, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.33, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.84, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.79, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.25, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.8, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.82, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.44, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.26, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.36, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CLORAZEPATE DIPOTASSIUM 7.5 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "1310728301", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.25, "maximum": 7.52, "gross_charge": 8.0, "discounted_cash": 4.4, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.4, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.78, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.33, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.84, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.79, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.25, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.8, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.82, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.44, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.26, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.36, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Close tear duct opening", "code_information": [ { "code": "68760", "type": "HCPCS" }, { "code": "68761", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 220.34, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 163.22, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 2066.16, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 3749.09, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 220.34, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 3749.09, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Closed tx septal&nose fx", "code_information": [ { "code": "21337", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2390.47, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1770.72, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 8224.54, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 14923.57, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2390.47, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 14923.57, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Closure of eyelid by suture", "code_information": [ { "code": "67875", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 713.91, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 528.82, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 9427.07, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 17177.56, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 713.91, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 17177.56, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Closure of vagina", "code_information": [ { "code": "57120", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 3638.66, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2695.3, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 15295.43, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 27753.79, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3638.66, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 27753.79, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Closure of windpipe lesion", "code_information": [ { "code": "31820", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2390.47, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1770.72, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 9643.88, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 17498.97, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2390.47, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 17498.97, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CLOTRIMAZOLE 1 % EX CREA", "drug_information": { "unit": "15.000000", "type": "GR" }, "code_information": [ { "code": "45802043401", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.01, "maximum": 6.72, "gross_charge": 7.15, "discounted_cash": 3.93, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.15, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.9, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.72, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.06, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.08, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.43, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.28, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.28, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.72, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.29, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.01, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.08, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.36, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.52, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.86, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.72, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.6, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.9, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.68, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.36, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.29, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.15, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.9, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CLOTRIMAZOLE 1 % EX SOLN", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "10135067181", "type": "NDC" } ], "standard_charges": [ { "minimum": 8.59, "maximum": 28.67, "gross_charge": 30.5, "discounted_cash": 16.78, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.69, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.65, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.4, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.83, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.88, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.64, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.27, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.24, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.67, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.84, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.59, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.93, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.88, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.74, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.67, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.88, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.65, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.25, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.88, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.84, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.69, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.65, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CLOTRIMAZOLE 1 % VA CREA", "drug_information": { "unit": "45.000000", "type": "GR" }, "code_information": [ { "code": "61269022063", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.56, "maximum": 8.54, "gross_charge": 9.08, "discounted_cash": 4.99, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.27, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.96, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.26, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.69, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.36, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.44, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.43, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.54, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.99, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.56, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.72, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.81, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.17, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.54, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.11, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.96, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.22, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.81, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.99, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.27, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.96, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CLOTRIMAZOLE 1% EX SOLN (OTIC USE)", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "10135067181_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 8.59, "maximum": 28.67, "gross_charge": 30.5, "discounted_cash": 16.78, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.69, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.65, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.4, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.83, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.88, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.64, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.27, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.24, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.67, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.84, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.59, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.93, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.88, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.74, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.67, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.88, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.65, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.25, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.88, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.84, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.69, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.65, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CLOTRIMAZOLE 10 MG MT TROC", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "1657168607", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CLOTRIMAZOLE-BETAMETHASONE 1-0.05 % EX CREA", "drug_information": { "unit": "15.000000", "type": "GR" }, "code_information": [ { "code": "00168025815", "type": "NDC" } ], "standard_charges": [ { "minimum": 5.04, "maximum": 16.81, "gross_charge": 17.88, "discounted_cash": 9.83, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.37, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.76, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.3, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.14, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.2, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.58, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.71, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.69, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.81, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.73, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.04, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.2, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.41, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.3, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.16, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.81, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.0, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.76, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.21, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.41, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.73, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.37, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.76, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CLOZAPINE 100 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687041501", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CLOZAPINE 100 MG PO TBDP", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00093541984", "type": "NDC" } ], "standard_charges": [ { "minimum": 4.17, "maximum": 13.92, "gross_charge": 14.81, "discounted_cash": 8.15, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.59, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.09, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.85, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.54, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.31, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.11, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.87, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.86, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.92, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.03, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.17, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.59, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.11, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.22, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.07, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.92, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.6, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.09, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.77, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.11, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.03, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.59, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.09, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CLOZAPINE 200 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687042601", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CLOZAPINE 25 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687040401", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CLOZAPINE 25 MG PO TBDP", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00093541784", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.19, "maximum": 3.98, "gross_charge": 4.23, "discounted_cash": 2.33, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.45, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.31, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.38, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.58, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.23, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.03, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.53, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.53, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.98, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.72, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.19, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.6, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.17, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.49, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.88, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.98, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.31, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.31, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.36, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.17, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.72, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.45, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.31, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CLOZAPINE 50 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687054801", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CLOZAPINE 50 MG/ML PO SUSP", "drug_information": { "unit": "0.500000", "type": "UN" }, "code_information": [ { "code": "52817060138", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.69, "maximum": 8.98, "gross_charge": 9.55, "discounted_cash": 5.25, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.54, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.21, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.64, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.09, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.78, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.58, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.72, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.71, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.98, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.4, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.69, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.12, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.16, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.36, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.49, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.98, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.48, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.21, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.59, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.16, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.4, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.54, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.21, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Clsd tx nsl fx mnpj wo stblj", "code_information": [ { "code": "21315", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1091.85, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 808.78, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 3442.96, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 6247.31, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1091.85, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 6247.31, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Clsd tx nsl fx w/mnpj&stablj", "code_information": [ { "code": "21320", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2390.47, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1770.72, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 6082.4, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 11036.6, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2390.47, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 11036.6, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Cltx sho dslc w/mnpj wo anes", "code_information": [ { "code": "23650", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 176.82, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 1195.36, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 2169.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 176.82, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 2169.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Cmbn ant pst colprhy", "code_information": [ { "code": "57260", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 3638.66, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2695.3, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 24168.84, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 43854.76, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3638.66, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 43854.76, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Cmbn ap colprhy w/ntrcl rpr", "code_information": [ { "code": "57265", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 3638.66, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2695.3, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 19585.4, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 35538.02, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3638.66, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 35538.02, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Cmplx rpr e/n/e/l 1.1-2.5 cm", "code_information": [ { "code": "13151", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 451.2, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 334.22, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 3278.56, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 5949.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 451.2, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 5949.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Cmplx rpr e/n/e/l 2.6-7.5 cm", "code_information": [ { "code": "13152", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 451.2, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 3848.96, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 6984.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 451.2, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 6984.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Cmplx rpr f/c/c/m/n/ax/g/h/f", "code_information": [ { "code": "13131", "type": "HCPCS" }, { "code": "13132", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 451.2, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 2311.36, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 4194.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 294.49, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 451.2, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 4194.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Cmplx rpr s/a/l 1.1-2.5 cm", "code_information": [ { "code": "13120", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 451.2, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 2728.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 4950.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 451.2, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 4950.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Cmplx rpr s/a/l 2.6-7.5 cm", "code_information": [ { "code": "13121", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 451.2, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 2354.12, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 4271.58, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 451.2, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 4271.58, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Cmplx rpr trunk 1.1-2.5 cm", "code_information": [ { "code": "13100", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 451.2, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 3625.76, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 6579.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 451.2, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 6579.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Cmplx rpr trunk 2.6-7.5 cm", "code_information": [ { "code": "13101", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 451.2, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 334.22, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 2346.08, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 4257.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 451.2, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 4257.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "COAG FACT XA INACTIVATED-ZHZO 200 MG IV SOLR", "drug_information": { "unit": "20.000000", "type": "UN" }, "code_information": [ { "code": "00310320004_4", "type": "NDC" } ], "standard_charges": [ { "minimum": 72.07, "maximum": 6879.63, "gross_charge": 7318.75, "discounted_cash": 4025.31, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4244.88, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 72.07, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5855.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6198.98, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2129.76, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3513.0, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4383.93, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4376.61, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6879.63, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6440.5, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2062.42, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6220.94, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5489.06, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2578.4, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4976.75, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6879.63, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5730.58, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 97.29, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5818.41, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5489.06, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6440.5, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4244.88, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 72.07, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "COAG FACT XA INACTIVATED-ZHZO 200 MG IV SOLR|DISCARDED DRUG NOT ADMINISTERED", "drug_information": { "unit": "20.000000", "type": "UN" }, "code_information": [ { "code": "00310320004", "type": "NDC" } ], "standard_charges": [ { "minimum": 72.07, "maximum": 6813.83, "gross_charge": 7248.75, "discounted_cash": 3986.81, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4204.28, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 72.07, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5799.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6139.69, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2109.39, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3479.4, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4342.0, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4334.75, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6813.83, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6378.9, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2042.7, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6161.44, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5436.56, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2553.73, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4929.15, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6813.83, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5675.77, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 97.29, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5762.76, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5436.56, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6378.9, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", 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}, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6198.98, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2129.76, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3513.0, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4383.93, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4376.61, "standard_charge_percentage": 60.0, "methodology": 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total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 72.07, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "COAG FACT XA INACTIVATED-ZHZO IVPB BOLUS|DISCARDED DRUG NOT ADMINISTERED", "drug_information": { "unit": "20.000000", "type": "UN" }, "code_information": [ { "code": "00310320004_3", "type": "NDC" } ], "standard_charges": [ { "minimum": 72.07, "maximum": 6813.83, "gross_charge": 7248.75, "discounted_cash": 3986.81, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4204.28, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 72.07, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5799.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6139.69, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2109.39, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3479.4, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", 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"plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6161.44, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5436.56, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2553.73, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4929.15, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6813.83, 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"standard_charge_dollar": 6378.9, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4204.28, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 72.07, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "COAGULATION FACTOR IX (RECOMB) 1000 UNITS IV KIT", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "58394063503_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.01, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.01, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.36, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.01, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "COAGULATION FACTOR IX (RECOMB) 1000 UNITS IV KIT|DISCARDED DRUG NOT ADMINISTERED", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "58394063503", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.7, "maximum": 2.32, "gross_charge": 2.47, "discounted_cash": 1.36, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.43, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.01, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.98, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.09, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.72, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.19, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.48, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.48, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.17, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.7, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.1, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.85, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.87, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.68, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.93, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.36, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.96, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.85, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.17, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.43, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.01, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "COAGULATION FACTOR IX (RECOMB) 2000 UNITS IV KIT", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "58394063603_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.01, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.01, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.36, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.01, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "COAGULATION FACTOR IX (RECOMB) 2000 UNITS IV KIT|DISCARDED DRUG NOT ADMINISTERED", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "58394063603", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.7, "maximum": 2.32, "gross_charge": 2.47, "discounted_cash": 1.36, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.43, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.01, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.98, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.09, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.72, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.19, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.48, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.48, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.17, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.7, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.1, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.85, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.87, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.68, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.93, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.36, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.96, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.85, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.17, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.43, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.01, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "COAGULATION FACTOR IX (RECOMB) 250 UNITS IV KIT", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "58394063303_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.01, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.01, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.36, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.01, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "COAGULATION FACTOR IX (RECOMB) 250 UNITS IV KIT|DISCARDED DRUG NOT ADMINISTERED", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "58394063303", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.74, "maximum": 2.48, "gross_charge": 2.64, "discounted_cash": 1.45, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.53, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.01, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.11, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.24, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.77, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.27, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.58, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.58, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.48, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.74, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.24, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.98, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.93, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.48, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.07, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.36, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.1, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.98, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.53, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.01, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "COAGULATION FACTOR IX (RECOMB) 3000 UNITS IV KIT", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "58394063703_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.01, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.01, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.36, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.01, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "COAGULATION FACTOR IX (RECOMB) 3000 UNITS IV KIT|DISCARDED DRUG NOT ADMINISTERED", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "58394063703", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.7, "maximum": 2.32, "gross_charge": 2.47, "discounted_cash": 1.36, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.43, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.01, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.98, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.09, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.72, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.19, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.48, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.48, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.17, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.7, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.1, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.85, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.87, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.68, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.93, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.36, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.96, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.85, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.17, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.43, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.01, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "COAGULATION FACTOR IX (RECOMB) 500 UNITS IV KIT", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "58394063403_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.01, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { 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"percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, 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"payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.01, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "COAGULATION FACTOR IX (RECOMB) 500 UNITS IV KIT|DISCARDED DRUG NOT ADMINISTERED", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "58394063403", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.74, "maximum": 2.45, "gross_charge": 2.61, "discounted_cash": 1.44, "setting": "inpatient", 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charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.77, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.45, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.04, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.36, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.07, "standard_charge_percentage": 80.0, "methodology": 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"UN" }, "code_information": [ { "code": "00169720101", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.38, "maximum": 5542.65, "gross_charge": 5896.44, "discounted_cash": 3243.04, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3419.94, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.38, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4717.15, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 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{ "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2077.32, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4009.58, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5542.65, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4616.91, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.86, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4687.67, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4422.33, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5188.87, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3419.94, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.38, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "COAGULATION FACTOR VIIA RECOMB 2 MG IV SOLR", "drug_information": { "unit": "2.000000", "type": "UN" }, "code_information": [ { "code": "00169720201", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.38, "maximum": 10864.9, "gross_charge": 11558.4, "discounted_cash": 6357.12, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 6703.87, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.38, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9246.72, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9789.96, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3363.49, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5548.03, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6923.48, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 6911.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10864.9, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10171.39, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3257.16, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9824.64, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8668.8, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 4072.02, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7859.71, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 10864.9, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 9050.23, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.86, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 9188.93, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8668.8, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10171.39, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6703.87, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.38, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "COAGULATION FACTOR VIIA RECOMB 5 MG IV SOLR", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "00169720501", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.38, "maximum": 27713.21, "gross_charge": 29482.14, "discounted_cash": 16215.18, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 17099.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { 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"methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 25944.28, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 17099.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.38, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "COAGULATION FACTOR VIIA RECOMB 8 MG IV SOLR", "drug_information": { "unit": "8.000000", "type": "UN" }, "code_information": [ { "code": "00169720801", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.38, "maximum": 44341.12, "gross_charge": 47171.4, "discounted_cash": 25944.27, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 27359.41, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.38, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37737.12, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39954.18, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", 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"additional_generic_notes": "" } ] }, { "description": "COAL TAR EXTRACT 20 % SOLN", "drug_information": { "unit": "473.000000", "type": "UN" }, "code_information": [ { "code": "00395061716", "type": "NDC" } ], "standard_charges": [ { "minimum": 16.93, "maximum": 1158.0, "gross_charge": 60.08, "discounted_cash": 33.04, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.85, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.8, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.15, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.48, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.84, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.99, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.93, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 56.48, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.87, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.93, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 51.07, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.06, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.17, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.85, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 56.48, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.04, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.8, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.76, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.06, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.87, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.85, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.8, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "COBICISTAT 150 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "61958140101", "type": "NDC" } ], "standard_charges": [ { "minimum": 6.32, "maximum": 21.08, "gross_charge": 22.43, "discounted_cash": 12.34, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.01, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.25, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.94, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.53, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.77, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.44, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.41, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.08, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.74, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.32, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.07, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.82, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.9, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.25, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.08, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.56, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.25, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.83, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.82, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.74, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.01, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.25, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "COCAINE HCL 40 MG/ML NA SOLN", "drug_information": { "unit": "4.000000", "type": "UN" }, "code_information": [ { "code": "81665030102", "type": "NDC" } ], "standard_charges": [ { "minimum": 236.27, "maximum": 788.13, "gross_charge": 838.44, "discounted_cash": 461.14, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 486.3, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 457.79, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 670.75, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 710.16, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 243.99, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 402.45, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 502.23, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 501.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 788.13, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 737.83, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 236.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 712.67, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 628.83, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 295.38, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 570.14, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 788.13, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 656.5, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 457.79, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 666.56, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 628.83, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 737.83, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 486.3, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 457.79, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CODEINE SULFATE 15 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00054024324", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.25, "maximum": 7.52, "gross_charge": 8.0, "discounted_cash": 4.4, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.4, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.78, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.33, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.84, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.79, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.25, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.8, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.82, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.44, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.26, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.36, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CODEINE SULFATE 30 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00054024424", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.25, "maximum": 7.52, "gross_charge": 8.0, "discounted_cash": 4.4, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.4, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.78, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.33, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.84, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.79, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.25, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.8, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.82, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.44, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.26, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.36, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "COENZYME Q10 100 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "11845013198", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "COENZYME Q10 200 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "54022800201", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "COENZYME Q10 50 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00904561646", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "COENZYME Q10 50 MG/5ML PO LIQD", "drug_information": { "unit": "120.000000", "type": "UN" }, "code_information": [ { "code": "99888000014", "type": "NDC" } ], "standard_charges": [ { "minimum": 14.03, "maximum": 46.81, "gross_charge": 49.8, "discounted_cash": 27.39, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.88, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.19, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.84, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.18, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.49, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.9, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.83, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.81, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.82, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.03, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.33, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.35, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.54, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.86, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.81, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.99, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.19, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.59, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.35, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.82, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.88, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.19, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "COLCHICINE 0.3 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "R0591256201", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "COLCHICINE 0.6 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "50268018715", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.52, "maximum": 5.09, "gross_charge": 5.41, "discounted_cash": 2.98, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.14, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.95, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.33, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.58, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.57, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.24, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.24, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.09, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.76, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.52, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.6, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.06, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.91, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.68, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.09, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.24, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.95, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.3, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.06, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.76, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.14, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.95, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Colgn crs-link crn&pachymtry", "code_information": [ { "code": "0402T", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1719.62, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1273.8, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 14274.13, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 25900.63, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1719.62, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 25900.63, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "COLISTIMETHATE INHALATION SYRINGE", "drug_information": { "unit": "2.000000", "type": "UN" }, "code_information": [ { "code": "08252007501", "type": "NDC" } ], "standard_charges": [ { "minimum": 37.56, "maximum": 125.27, "gross_charge": 133.27, "discounted_cash": 73.3, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 77.3, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 72.77, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 106.62, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 112.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.78, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.97, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 79.83, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 79.7, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 125.27, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 117.28, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.56, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 113.28, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 99.95, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.95, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 90.62, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 125.27, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 104.35, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 72.77, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 105.95, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 99.95, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 117.28, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 77.3, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 72.77, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "COLISTIMETHATE SODIUM (CBA) 150 MG IJ SOLR", "drug_information": { "unit": "2.000000", "type": "UN" }, "code_information": [ { "code": "70594002301", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "COLISTIN 75 MG/ML SYRINGE (PEDS)", "drug_information": { "unit": "2.000000", "type": "UN" }, "code_information": [ { "code": "08252007501_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 37.56, "maximum": 125.27, "gross_charge": 133.27, "discounted_cash": 73.3, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 77.3, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 72.77, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 106.62, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 112.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.78, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.97, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 79.83, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 79.7, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 125.27, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 117.28, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.56, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 113.28, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 99.95, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.95, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 90.62, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 125.27, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 104.35, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 72.77, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 105.95, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 99.95, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 117.28, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 77.3, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 72.77, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "COLLAGENASE 250 UNIT/GM EX OINT", "drug_information": { "unit": "30.000000", "type": "GR" }, "code_information": [ { "code": "50484001030", "type": "NDC" } ], "standard_charges": [ { "minimum": 180.25, "maximum": 601.27, "gross_charge": 639.65, "discounted_cash": 351.81, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 371.0, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 349.25, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 511.72, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 541.78, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 186.14, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 307.03, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 383.15, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 382.51, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 601.27, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 562.89, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 180.25, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 543.7, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 479.74, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 225.35, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 434.96, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 601.27, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 500.85, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 349.25, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 508.52, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 479.74, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 562.89, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 371.0, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 349.25, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "COLLAGENASE CLOSTRID HISTOLYT 0.9 MG IJ SOLR", "drug_information": { "unit": "0.900000", "type": "ME" }, "code_information": [ { "code": "66887000301", "type": "NDC" } ], "standard_charges": [ { "minimum": 38.85, "maximum": 19292.21, "gross_charge": 20523.63, "discounted_cash": 11288.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 11903.71, "standard_charge_percentage": 58.0, "methodology": "percent of total billed 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charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 19292.21, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 16070.0, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.45, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 15189.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15392.72, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 18060.79, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 11903.71, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.85, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "COLLODION FLEXIBLE EX LIQD", "drug_information": { "unit": "100.000000", "type": "UN" }, "code_information": [ { "code": "38779062505", "type": "NDC" } ], "standard_charges": [ { "minimum": 12.37, "maximum": 41.25, "gross_charge": 43.88, "discounted_cash": 24.13, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.45, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.1, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", 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"additional_payer_notes": "N/A", "standard_charge_dollar": 38.61, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.37, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.3, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.91, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.46, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.84, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.25, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.36, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.88, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.91, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.61, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.45, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Colon ca scrn not hi rsk ind", "code_information": [ { "code": "G0121", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 672.02, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 497.79, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 2732.96, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 4959.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 672.02, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 4959.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Colonoscopy & polypectomy", "code_information": [ { "code": "44392", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 869.1, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 643.78, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 3261.2, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 5917.5, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 869.1, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 5917.5, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Colonoscopy and biopsy", "code_information": [ { "code": "45380", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 869.1, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 643.78, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 2589.13, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 5832.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 869.1, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 5832.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Colonoscopy submucous njx", "code_information": [ { "code": "45381", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 869.1, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 643.78, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 4020.54, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 7295.35, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 869.1, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 7295.35, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Colonoscopy thru stoma spx", "code_information": [ { "code": "44388", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 672.02, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 497.79, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 3369.82, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 6114.6, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 672.02, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 6114.6, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Colonoscopy w/ablation", "code_information": [ { "code": "45388", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 869.1, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 643.78, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 4074.36, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 7393.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 869.1, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 7393.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Colonoscopy w/balloon dilat", "code_information": [ { "code": "45386", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 869.1, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 643.78, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 4024.72, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 7302.92, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 869.1, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 7302.92, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Colonoscopy w/band ligation", "code_information": [ { "code": "45398", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 869.1, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 643.78, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 3139.68, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 5697.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 869.1, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 5697.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Colonoscopy w/control bleed", "code_information": [ { "code": "45382", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 869.1, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 643.78, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 3826.5, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 6943.25, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 869.1, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 6943.25, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Colonoscopy w/dilation", "code_information": [ { "code": "44405", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 869.1, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 643.78, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 4500.88, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 8166.92, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 869.1, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 8166.92, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Colonoscopy w/endoscope us", "code_information": [ { "code": "45391", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 869.1, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 643.78, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 4430.54, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 8039.3, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 869.1, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 8039.3, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Colonoscopy w/endoscopic fnb", "code_information": [ { "code": "45392", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 869.1, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 643.78, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 7159.13, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 12990.34, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 869.1, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 12990.34, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Colonoscopy w/fb removal", "code_information": [ { "code": "45379", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 869.1, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 643.78, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 3301.52, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 5990.67, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 869.1, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 5990.67, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Colonoscopy w/lesion removal", "code_information": [ { "code": "45384", "type": "HCPCS" }, { "code": "45385", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 869.1, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 643.78, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 3214.08, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 5832.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 869.1, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 5832.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Colonoscopy w/resection", "code_information": [ { "code": "44403", "type": "HCPCS" }, { "code": "45390", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2021.42, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 643.78, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1497.34, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 5465.07, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 9916.47, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 869.1, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2021.42, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 9916.47, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Colonoscopy w/snare", "code_information": [ { "code": "44394", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 869.1, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 643.78, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 3566.24, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 6471.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 869.1, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 6471.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Colonoscopy w/stent plcmt", "code_information": [ { "code": "45389", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4387.82, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3250.23, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 11658.79, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 21155.07, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4387.82, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 21155.07, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Colonoscopy with biopsy", "code_information": [ { "code": "44389", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 869.1, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 643.78, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 4865.76, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 8829.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 869.1, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 8829.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Colorectal scrn; hi risk ind", "code_information": [ { "code": "G0105", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 672.02, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 497.79, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 2732.96, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 4959.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 672.02, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 4959.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Colpopexy extraperitoneal", "code_information": [ { "code": "57282", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 5450.71, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4037.57, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 16886.03, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 30639.96, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5450.71, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 30639.96, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Colpopexy intraperitoneal", "code_information": [ { "code": "57283", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 5450.71, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4037.57, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 25390.63, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 46071.72, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5450.71, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 46071.72, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Complete removal of vulva", "code_information": [ { "code": "56625", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2343.63, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1736.02, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 17020.51, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 30884.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2343.63, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 30884.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "COMPLEX B-100 PO TBCR", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "40985022282", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", 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"PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Complex cystometrogram", "code_information": [ { "code": "51726", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 179.27, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 132.79, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 2053.44, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 3726.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 179.27, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", 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"payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.67, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.89, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.3, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.39, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.32, 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"standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.63, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.67, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.89, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.3, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", 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"standard_charge_dollar": 5.69, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.39, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.72, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.7, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.39, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.21, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.51, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.63, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.67, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.89, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.3, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.39, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.68, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.55, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.67, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.21, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.34, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.68, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CONJ ESTROG-MEDROXYPROGEST ACE 0.625-5 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00046110811", "type": "NDC" } ], "standard_charges": [ { "minimum": 5.51, "maximum": 18.39, "gross_charge": 19.56, "discounted_cash": 10.76, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.34, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.68, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.65, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.57, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.69, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.39, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.72, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.7, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.39, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.21, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.51, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.63, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.67, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.89, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.3, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.39, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.68, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.55, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.67, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.21, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.34, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.68, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Construction of vagina", "code_information": [ { "code": "57291", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 3638.66, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2695.3, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 32426.67, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 58838.75, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3638.66, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 58838.75, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Contour cranial bone lesion", "code_information": [ { "code": "21181", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4360.43, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3229.95, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 5989.8, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 10868.58, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4360.43, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 10868.58, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Contour of face bone lesion", "code_information": [ { "code": "21029", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2390.47, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1770.72, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 19843.13, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 36005.7, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2390.47, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 36005.7, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Control throat bleeding", "code_information": [ { "code": "42960", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 375.37, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 278.05, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 9450.64, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 17148.33, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 375.37, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 17148.33, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Conversion ext bil drg cath", "code_information": [ { "code": "47535", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2601.27, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1926.87, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 11835.25, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 21475.25, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2601.27, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 21475.25, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Convert nephrostomy catheter", "code_information": [ { "code": "50434", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1509.96, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1118.49, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 11286.63, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 20479.8, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1509.96, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 20479.8, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Conz of cervix w/scope leep", "code_information": [ { "code": "57461", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2343.63, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1736.02, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 6487.92, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 11772.45, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2343.63, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 11772.45, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "COPPER 0.2MG/ML SOLUTION", "drug_information": { "unit": "1.500000", "type": "UN" }, "code_information": [ { "code": "P0409409201", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "COPPER 400MCG/ML SOLUTION", "drug_information": { "unit": "0.750000", "type": "UN" }, "code_information": [ { "code": "P0074409201", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "COPPER CU 64 DOTATATE 1 MCI/ML IV SOLN", "drug_information": { "unit": "4.000000", "type": "UN" }, "code_information": [ { "code": "69945006401", "type": "NDC" } ], "standard_charges": [ { "minimum": 3127.98, "maximum": 10434.0, "gross_charge": 11100.0, "discounted_cash": 6105.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 6438.0, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 6060.6, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8880.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9401.7, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3230.1, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5328.0, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6648.9, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 6637.8, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10434.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9768.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3127.98, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9435.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8325.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3910.53, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7548.0, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 10434.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8691.3, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6060.6, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 8824.5, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8325.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9768.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6438.0, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6060.6, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Cor hlx vlgs double osteot", "code_information": [ { "code": "28299", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 5265.64, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3900.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 20444.35, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 37096.59, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5265.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 37096.59, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Cor hlx vlgs dstl mtar osteo", "code_information": [ { "code": "28296", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2391.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1771.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 11392.93, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 20672.66, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2391.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 20672.66, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Cor hlx vlgs jt arthrd", "code_information": [ { "code": "28297", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 9484.13, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 7025.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 30911.52, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 56109.07, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 9484.13, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 56109.07, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Cor hlx vlgs prx mtar osteot", "code_information": [ { "code": "28295", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2391.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1771.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 8862.42, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 16081.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2391.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 16081.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Cor hlx vlgs prx phlx osteot", "code_information": [ { "code": "28298", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 5265.64, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3900.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 16614.86, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 30147.93, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5265.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 30147.93, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Cor hlx vlgs rsc prx phlx bs", "code_information": [ { "code": "28292", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2391.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1771.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 12033.46, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 21834.9, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2391.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 21834.9, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Core ndl bx lng/med perq", "code_information": [ { "code": "32408", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1194.28, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 884.65, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 5168.32, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 9378.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1194.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 9378.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Corneal smear", "code_information": [ { "code": "65430", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 294.13, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 217.88, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 8192.21, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 14864.91, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 294.13, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 14864.91, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Corneal transplant", "code_information": [ { "code": "65710", "type": "HCPCS" }, { "code": "65730", "type": "HCPCS" }, { "code": "65755", "type": "HCPCS" }, { "code": "65750", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 3803.22, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2817.2, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2196.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 24542.16, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 44532.12, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3803.22, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2965.25, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 44532.12, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Corneal trnspl endothelial", "code_information": [ { "code": "65756", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2965.25, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2196.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 16794.97, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 30474.74, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2965.25, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 30474.74, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Coronary art/grft angio s&i", "code_information": [ { "code": "93455", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2370.82, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1756.16, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 12597.91, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 22859.15, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2370.82, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 22859.15, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Coronary artery angio s&i", "code_information": [ { "code": "93454", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2370.82, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1756.16, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 10600.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 19233.88, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2370.82, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 19233.88, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Correct finger deformity", "code_information": [ { "code": "26567", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2391.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1771.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 14486.79, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 26286.51, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2391.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 26286.51, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Correct inverted nipple(s)", "code_information": [ { "code": "19355", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2822.56, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2090.79, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 9002.4, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 16335.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2822.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 16335.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Correct metacarpal flaw", "code_information": [ { "code": "26565", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2391.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1771.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 12067.42, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 21896.52, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2391.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 21896.52, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Correct rectal prolapse", "code_information": [ { "code": "45541", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2021.42, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1497.34, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 7095.28, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 12874.5, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2021.42, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 12874.5, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Correction eyelid w/implant", "code_information": [ { "code": "67912", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1719.62, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1273.8, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 10803.49, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 19603.11, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1719.62, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 19603.11, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Corrj halux rigdus w/implt", "code_information": [ { "code": "28291", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 5265.64, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3900.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 11884.41, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 21564.45, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5265.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 21564.45, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Corrj halux rigdus w/o implt", "code_information": [ { "code": "28289", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2391.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1771.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 7425.12, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 13473.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2391.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 13473.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "COSYNTROPIN 0.25 MG IJ SOLR", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00548590000", "type": "NDC" } ], "standard_charges": [ { "minimum": 12.76, "maximum": 42.57, "gross_charge": 45.29, "discounted_cash": 24.91, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.27, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.73, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.23, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.36, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.18, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.74, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.13, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.08, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.57, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.86, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.76, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.97, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.96, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.57, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.46, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.73, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.01, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.97, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.86, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.27, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.73, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Cover eye w/membrane", "code_information": [ { "code": "65778", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 713.91, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 528.82, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 9941.08, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 18254.25, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 713.91, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 18254.25, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Cover eye w/membrane suture", "code_information": [ { "code": "65779", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2779.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2058.97, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 9182.99, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 16719.02, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2779.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 16719.02, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "COVID-19 MRNA VAC-TRIS(PFIZER) 30 MCG/0.3ML IM SUSY", "drug_information": { "unit": "0.300000", "type": "UN" }, "code_information": [ { "code": "00069243210", "type": "NDC" } ], "standard_charges": [ { "minimum": 102.51, "maximum": 341.93, "gross_charge": 363.76, "discounted_cash": 200.07, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 210.98, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 198.61, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 291.01, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 308.1, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 105.85, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 174.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 217.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 217.53, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 341.93, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 320.11, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 102.51, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 309.2, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 272.82, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 128.15, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 247.36, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 341.93, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 284.82, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 198.61, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 289.19, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 272.82, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 320.11, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 210.98, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 198.61, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "COVID-19MRNA VAC 6M-11Y MODERN 25 MCG/0.25ML IM SUSY", "drug_information": { "unit": "0.250000", "type": "UN" }, "code_information": [ { "code": "80777029180", "type": "NDC" } ], "standard_charges": [ { "minimum": 127.23, "maximum": 424.41, "gross_charge": 451.5, "discounted_cash": 248.33, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 261.87, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 246.52, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 361.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 382.42, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 131.39, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 216.72, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 270.45, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 270.0, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 424.41, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 397.32, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 127.23, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 383.78, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 338.63, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 159.06, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 307.02, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 424.41, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 353.52, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 246.52, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 358.94, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 338.63, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 397.32, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 261.87, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 246.52, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Craniofacial approach skull", "code_information": [ { "code": "61580", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 34573.25, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 62733.79, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 62733.79, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Create eardrum opening", "code_information": [ { "code": "69433", "type": "HCPCS" }, { "code": "69436", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1091.85, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 278.05, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 808.78, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 4860.46, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 8819.38, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 375.37, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1091.85, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 8819.38, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Create passage to kidney", "code_information": [ { "code": "52334", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2542.24, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1883.14, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 30110.09, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 54635.26, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2542.24, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 54635.26, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Create tear duct drain", "code_information": [ { "code": "68750", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2779.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2058.97, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 8165.39, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 14864.06, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2779.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 14864.06, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Create tear sac drain", "code_information": [ { "code": "68720", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2779.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2058.97, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 9078.43, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 16472.95, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2779.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 16472.95, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CRIZANLIZUMAB-TMCA 100 MG/10ML IV SOLN", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "00078088361", "type": "NDC" } ], "standard_charges": [ { "minimum": 70.18, "maximum": 6917.29, "gross_charge": 7358.82, "discounted_cash": 4047.35, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4268.12, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 70.18, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5887.06, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6232.92, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2141.42, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3532.23, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4407.93, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4400.57, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6917.29, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6475.76, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2073.72, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6255.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5519.12, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2592.51, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5004.0, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6917.29, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5761.96, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 94.75, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5850.26, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5519.12, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6475.76, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4268.12, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 70.18, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "CRIZOTINIB 250 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00069814020", "type": "NDC" } ], "standard_charges": [ { "minimum": 397.49, "maximum": 1325.9, "gross_charge": 1410.53, "discounted_cash": 775.79, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 818.11, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 770.15, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1128.42, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1194.72, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 410.46, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 677.05, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 844.91, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 843.5, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1325.9, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1241.27, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 397.49, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1198.95, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1057.9, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 496.93, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 959.16, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1325.9, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1104.44, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 770.15, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1121.37, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1057.9, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1241.27, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 818.11, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 770.15, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Crnop skull defect<5 cm diam", "code_information": [ { "code": "62140", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 57671.1, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 104645.14, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 104645.14, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Crnop skull defect>5 cm diam", "code_information": [ { "code": "62141", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 49410.41, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 89656.01, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 89656.01, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Crnop w/autograft>5 cm diam", "code_information": [ { "code": "62147", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 44561.15, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 80856.93, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 80856.93, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CROMOLYN SODIUM 100 MG/5ML PO CONC", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "42571013252", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CROMOLYN SODIUM 20 MG/2ML IN NEBU", "drug_information": { "unit": "2.000000", "type": "UN" }, "code_information": [ { "code": "00172640649", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.73, "maximum": 9.12, "gross_charge": 9.7, "discounted_cash": 5.34, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.63, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.3, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.76, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.22, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.82, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.66, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.81, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.8, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.12, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.54, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.73, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.25, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.28, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.42, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.6, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.12, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.6, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.3, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.71, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.28, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.54, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.63, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.3, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CROMOLYN SODIUM 4 % OP SOLN", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "61314023710", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CROMOLYN SODIUM 5.2 MG/ACT NA AERS", "drug_information": { "unit": "26.000000", "type": "UN" }, "code_information": [ { "code": "14832001101", "type": "NDC" } ], "standard_charges": [ { "minimum": 8.88, "maximum": 29.61, "gross_charge": 31.5, "discounted_cash": 17.33, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.27, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.2, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.68, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.17, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.12, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.87, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.84, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.61, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.72, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.88, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.78, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.63, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.1, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.42, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.61, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.66, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.2, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.04, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.63, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.72, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.27, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.2, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CROTALIDAE POLYVAL IMMUNE FAB IV SOLR", "drug_information": { "unit": "2.000000", "type": "UN" }, "code_information": [ { "code": "50633011012", "type": "NDC" } ], "standard_charges": [ { "minimum": 962.24, "maximum": 16333.33, "gross_charge": 17375.88, "discounted_cash": 9556.73, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 10078.01, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 962.24, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13900.7, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14717.37, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5056.38, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8340.42, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 10408.15, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 10390.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16333.33, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15290.77, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 4896.52, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14769.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13031.91, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 6121.52, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 11815.6, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 16333.33, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 13605.31, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1299.03, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 13813.82, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13031.91, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15290.77, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 10078.01, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 962.24, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "Cryoablate prostate", "code_information": [ { "code": "55873", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 6816.07, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5048.94, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 19113.47, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 34681.71, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6816.07, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 34681.71, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Cryopreserve stem cells", "code_information": [ { "code": "38207", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 322.25, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 8055.25, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 14616.39, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 322.25, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 14616.39, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CRYOSERV SOLN", "drug_information": { "unit": "50.000000", "type": "UN" }, "code_information": [ { "code": "67457017850", "type": "NDC" } ], "standard_charges": [ { "minimum": 26.26, "maximum": 1158.0, "gross_charge": 93.2, "discounted_cash": 51.26, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.06, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.89, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 80.9, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.12, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 44.74, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.83, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.73, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.61, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.02, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.26, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 79.22, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 69.9, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.83, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.38, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.61, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 72.98, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.89, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.09, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 69.9, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.02, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.06, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.89, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Cryosurgery anal lesion(s)", "code_information": [ { "code": "46916", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 146.46, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 4026.64, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 7306.4, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 146.46, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 7306.4, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Cryosurgery penis lesion(s)", "code_information": [ { "code": "54056", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 146.46, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 342.24, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 621.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 146.46, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 621.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CULTURELLE BABY IMMUNE+DIGEST PO LIQD", "drug_information": { "unit": "0.250000", "type": "UN" }, "code_information": [ { "code": "49100040053", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CUPRIC CHLORIDE 0.4 MG/ML IV SOLN", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "51754010304", "type": "NDC" } ], "standard_charges": [ { "minimum": 16.72, "maximum": 1158.0, "gross_charge": 59.33, "discounted_cash": 32.63, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.41, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.39, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 51.5, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.27, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.48, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.54, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.48, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.77, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.21, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.72, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.43, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 44.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.9, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.34, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.77, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.46, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.39, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.17, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 44.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.21, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.41, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.39, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Curette/treat cornea", "code_information": [ { "code": "65435", "type": "HCPCS" }, { "code": "65436", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1719.62, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 528.82, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1273.8, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 4357.36, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 7906.5, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 713.91, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1719.62, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 7906.5, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CYANOCOBALAMIN 1000 MCG/ML IJ SOLN", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "70069000510", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { 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"standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CYCLOBENZAPRINE HCL 10 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "1013559501", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CYCLOBENZAPRINE HCL 5 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68084075365", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CYCLOPENTOLATE HCL 0.5 % OP SOLN", "drug_information": { "unit": "15.000000", "type": "UN" }, "code_information": [ { "code": "00065039515", "type": "NDC" } ], "standard_charges": [ { "minimum": 66.84, "maximum": 222.95, "gross_charge": 237.18, "discounted_cash": 130.45, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 137.56, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 129.5, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 189.74, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 200.89, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 69.02, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 113.85, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 142.07, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 141.83, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 222.95, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 208.72, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 66.84, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 201.6, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 177.89, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 83.56, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 161.28, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 222.95, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 185.71, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 129.5, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 188.56, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 177.89, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 208.72, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 137.56, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 129.5, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CYCLOPENTOLATE HCL 1 % OP SOLN", "drug_information": { "unit": "15.000000", "type": "UN" }, "code_information": [ { "code": "61314039603", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CYCLOPENTOLATE HCL 2 % OP SOLN", "drug_information": { "unit": "2.000000", "type": "UN" }, "code_information": [ { "code": "00065039702", "type": "NDC" } ], "standard_charges": [ { "minimum": 25.51, "maximum": 85.1, "gross_charge": 90.53, "discounted_cash": 49.79, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.51, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.43, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 72.42, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 76.68, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.34, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.45, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.23, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.14, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 85.1, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 79.67, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.51, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 76.95, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 67.9, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.89, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.56, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 85.1, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 70.88, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.43, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 71.97, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 67.9, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 79.67, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.51, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.43, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CYCLOPENTOLATE-PHENYLEPHRINE 0.2-1 % OP SOLN", "drug_information": { "unit": "2.000000", "type": "UN" }, "code_information": [ { "code": "00065035902", "type": "NDC" } ], "standard_charges": [ { "minimum": 20.37, "maximum": 67.96, "gross_charge": 72.3, "discounted_cash": 39.77, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.93, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.48, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 57.84, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.24, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.04, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.7, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.31, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.24, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 67.96, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.62, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.37, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.46, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.23, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.47, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.16, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 67.96, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 56.61, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.48, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 57.48, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.23, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.62, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.93, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.48, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CYCLOPHOSPHAMIDE 1 G IJ SOLR", "drug_information": { "unit": "50.000000", "type": "UN" }, "code_information": [ { "code": "25021024851", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.55, "maximum": 336.17, "gross_charge": 357.63, "discounted_cash": 196.7, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 207.43, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.55, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 286.1, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 302.91, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 104.07, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 171.66, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 214.22, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 213.86, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 336.17, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 314.71, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 100.78, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 303.99, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 268.22, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 125.99, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 243.19, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 336.17, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 280.02, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.74, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 284.32, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 268.22, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 314.71, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 207.43, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.55, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "CYCLOPHOSPHAMIDE 25 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "54879002101", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.82, "maximum": 6.06, "gross_charge": 6.45, "discounted_cash": 3.55, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.74, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.16, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.46, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.88, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.1, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.86, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.86, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.06, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.68, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.82, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.48, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.84, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.27, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.39, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.06, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.05, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.13, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.84, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.68, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.74, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CYCLOPHOSPHAMIDE 5 MG/ML SUSPENSION", "drug_information": { "unit": "100.000000", "type": "UN" }, "code_information": [ { "code": "P0054412925", "type": "NDC" } ], "standard_charges": [ { "minimum": 336.04, "maximum": 1120.93, "gross_charge": 1192.48, "discounted_cash": 655.86, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 691.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 651.09, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 953.98, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1010.03, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 347.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 572.39, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 714.3, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 713.1, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1120.93, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1049.38, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 336.04, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1013.61, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 894.36, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 420.11, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 810.89, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1120.93, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 933.71, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 651.09, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 948.02, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 894.36, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1049.38, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 691.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 651.09, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CYCLOPHOSPHAMIDE 50 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "54879002201", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.55, "maximum": 8.52, "gross_charge": 9.06, "discounted_cash": 4.98, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.25, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.95, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.25, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.67, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.35, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.43, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.42, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.97, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.55, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.7, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.8, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.19, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.16, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.09, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.95, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.8, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.97, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.25, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.95, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CYCLOPHOSPHAMIDE 500 MG IJ SOLR", "drug_information": { "unit": "25.000000", "type": "UN" }, "code_information": [ { "code": "25021024750", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.55, "maximum": 156.34, "gross_charge": 166.32, "discounted_cash": 91.48, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.47, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.55, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 133.06, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 140.87, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 48.4, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 79.83, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 99.63, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 99.46, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 156.34, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 146.36, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.87, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 141.37, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 124.74, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 58.59, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 113.1, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 156.34, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 130.23, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.74, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 132.22, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 124.74, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 146.36, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.47, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.55, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "CYCLOSERINE 250 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "13845120202", "type": "NDC" } ], "standard_charges": [ { "minimum": 53.25, "maximum": 177.62, "gross_charge": 188.96, "discounted_cash": 103.93, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 109.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.17, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 151.17, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 160.05, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.99, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 90.7, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 113.19, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 113.0, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 177.62, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 166.28, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 53.25, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 160.62, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 141.72, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 66.57, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 128.49, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 177.62, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 147.96, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.17, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 150.22, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 141.72, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 166.28, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 109.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.17, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CYCLOSPORINE 0.05 % OP EMUL", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60505620201", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CYCLOSPORINE 50 MG/ML IV SOLN", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "00078010901", "type": "NDC" } ], "standard_charges": [ { "minimum": 52.38, "maximum": 174.73, "gross_charge": 185.88, "discounted_cash": 102.23, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 107.81, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 101.49, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 148.7, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 157.44, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.09, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 89.22, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 111.34, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 111.16, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 174.73, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 163.57, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.38, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 158.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 139.41, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.49, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 126.4, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 174.73, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 145.54, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 101.49, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 147.77, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 139.41, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 163.57, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 107.81, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 101.49, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CYCLOSPORINE MODIFIED 100 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00078024815", "type": "NDC" } ], "standard_charges": [ { "minimum": 6.83, "maximum": 22.78, "gross_charge": 24.23, "discounted_cash": 13.33, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.05, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.23, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.38, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.52, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.05, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.63, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.51, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.49, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.78, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.32, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.83, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.6, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.17, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.54, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.48, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.78, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.97, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.23, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.26, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.17, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.32, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.05, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.23, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CYCLOSPORINE MODIFIED 100 MG/ML PO SOLN", "drug_information": { "unit": "50.000000", "type": "UN" }, "code_information": [ { "code": "00078027422", "type": "NDC" } ], "standard_charges": [ { "minimum": 372.12, "maximum": 1241.27, "gross_charge": 1320.5, "discounted_cash": 726.28, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 765.89, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 720.99, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1056.4, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1118.46, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 384.27, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 633.84, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 790.98, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 789.66, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1241.27, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1162.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 372.12, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1122.43, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 990.38, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 465.21, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 897.94, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1241.27, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1033.95, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 720.99, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1049.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 990.38, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1162.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 765.89, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 720.99, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CYCLOSPORINE MODIFIED 25 MG PO CAPS", "drug_information": { "unit": "2.000000", "type": "UN" }, "code_information": [ { "code": "00078024615", "type": "NDC" } ], "standard_charges": [ { "minimum": 3.42, "maximum": 11.4, "gross_charge": 12.13, "discounted_cash": 6.67, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.62, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.7, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.27, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.53, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.82, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.27, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.25, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.67, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.42, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.31, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.1, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.27, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.25, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.5, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.62, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.64, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.1, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.67, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.62, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CYCLOSPORINE VAGINAL CREAM (PTL)", "drug_information": { "unit": "60.000000", "type": "GR" }, "code_information": [ { "code": "00000000027", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CYPROHEPTADINE HCL 2 MG/5ML PO SYRP", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "64980050448", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CYPROHEPTADINE HCL 4 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "50268018915", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CYSTADANE PO POWD", "drug_information": { "unit": "180.000000", "type": "GR" }, "code_information": [ { "code": "52276040001", "type": "NDC" } ], "standard_charges": [ { "minimum": 1076.02, "maximum": 3589.28, "gross_charge": 3818.38, "discounted_cash": 2100.11, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2214.66, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2084.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3054.7, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3234.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1111.15, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1832.82, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2287.21, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2283.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3589.28, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3360.17, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1076.02, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3245.62, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2863.79, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1345.22, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2596.5, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3589.28, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2989.79, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2084.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3035.61, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2863.79, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3360.17, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2214.66, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2084.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CYSTEINE HCL 50 MG/ML IV SOLN", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "51754100703", "type": "NDC" } ], "standard_charges": [ { "minimum": 70.0, "maximum": 1158.0, "gross_charge": 248.41, "discounted_cash": 136.63, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 144.08, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 135.63, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 215.62, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 72.29, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 119.24, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 148.8, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 148.55, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 233.51, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 218.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 70.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 211.15, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 186.31, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.51, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 168.92, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 233.51, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 194.51, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 135.63, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 197.49, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 186.31, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 218.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 144.08, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 135.63, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Cysto impl 4 or more", "code_information": [ { "code": "C9740", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 6816.07, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5048.94, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 20569.87, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 37324.36, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6816.07, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 37324.36, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Cysto w/ureter stricture tx", "code_information": [ { "code": "52341", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2542.24, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1883.14, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 6937.53, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 12588.26, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2542.24, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 12588.26, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Cysto/uretero stricture tx", "code_information": [ { "code": "52344", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2542.24, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1883.14, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 10553.17, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 19148.91, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2542.24, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 19148.91, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Cysto/uretero w/lithotripsy", "code_information": [ { "code": "52356", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 3747.14, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2775.66, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 14870.24, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 27012.92, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3747.14, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 27012.92, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Cysto/uretero w/up stricture", "code_information": [ { "code": "52345", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2542.24, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1883.14, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 10420.71, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 18908.54, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2542.24, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 18908.54, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Cystometrogram w/vp", "code_information": [ { "code": "51728", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 491.99, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 364.44, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 8688.57, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 15801.55, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 491.99, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 15801.55, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Cystoscopy", "code_information": [ { "code": "52000", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 491.99, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 364.44, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 6986.86, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 12677.78, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 491.99, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 12677.78, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Cystoscopy & duct catheter", "code_information": [ { "code": "52010", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 491.99, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 364.44, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 12177.93, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 22097.05, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 491.99, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 22097.05, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Cystoscopy & revise urethra", "code_information": [ { "code": "52270", "type": "HCPCS" }, { "code": "52275", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1509.96, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1118.49, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 7025.84, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 12765.23, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1509.96, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 12765.23, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Cystoscopy & ureter catheter", "code_information": [ { "code": "52005", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1509.96, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1118.49, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 9234.98, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 16757.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1509.96, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 16757.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Cystoscopy and biopsy", "code_information": [ { "code": "52007", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2542.24, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1883.14, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 10765.45, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 19534.1, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2542.24, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 19534.1, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Cystoscopy and radiotracer", "code_information": [ { "code": "52250", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2542.24, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1883.14, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 10955.97, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 19879.78, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2542.24, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 19879.78, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Cystoscopy and treatment", "code_information": [ { "code": "52214", "type": "HCPCS" }, { "code": "52224", "type": "HCPCS" }, { "code": "52234", "type": "HCPCS" }, { "code": "52235", "type": "HCPCS" }, { "code": "52240", "type": "HCPCS" }, { "code": "52260", "type": "HCPCS" }, { "code": "52276", "type": "HCPCS" }, { "code": "52281", "type": "HCPCS" }, { "code": "52283", "type": "HCPCS" }, { "code": "52285", "type": "HCPCS" }, { "code": "52300", "type": "HCPCS" }, { "code": "52301", "type": "HCPCS" }, { "code": "52310", "type": "HCPCS" }, { "code": "52315", "type": "HCPCS" }, { "code": "52320", "type": "HCPCS" }, { "code": "52330", "type": "HCPCS" }, { "code": "52332", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 3747.14, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1883.14, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2775.66, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1118.49, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 364.44, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 10520.65, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 19089.9, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2542.24, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3747.14, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1509.96, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 491.99, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 19089.9, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Cystoscopy chemodenervation", "code_information": [ { "code": "52287", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1509.96, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1118.49, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 8627.42, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 15654.6, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1509.96, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 15654.6, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Cystoscopy implant stent", "code_information": [ { "code": "52282", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2542.24, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1883.14, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 7465.67, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 13546.59, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2542.24, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 13546.59, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Cystoscopy inject material", "code_information": [ { "code": "52327", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 3747.14, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2775.66, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 23479.57, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 42613.53, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3747.14, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 42613.53, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Cystoscopy prostatic imp 1-3", "code_information": [ { "code": "C9739", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 3747.14, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2775.66, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 13909.82, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 25239.6, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3747.14, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 25239.6, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Cystoscopy removal of clots", "code_information": [ { "code": "52001", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2542.24, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1883.14, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 25542.07, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 49713.69, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2542.24, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 49713.69, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Cystoscopy stone removal", "code_information": [ { "code": "52325", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 3747.14, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2775.66, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 44517.53, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 80777.75, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3747.14, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 80777.75, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Cystoscopy w/biopsy(s)", "code_information": [ { "code": "52204", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1509.96, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1118.49, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 9445.73, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 17139.43, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1509.96, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 17139.43, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Cystouretero & or pyeloscope", "code_information": [ { "code": "52351", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2542.24, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1883.14, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 11036.96, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 20026.75, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2542.24, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 20026.75, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Cystouretero w/biopsy", "code_information": [ { "code": "52354", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 3747.14, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2775.66, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 11761.79, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 21341.96, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3747.14, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 21341.96, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Cystouretero w/congen repr", "code_information": [ { "code": "52400", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2542.24, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1883.14, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 16113.14, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 29237.55, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2542.24, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 29237.55, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Cystouretero w/excise tumor", "code_information": [ { "code": "52355", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 3747.14, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2775.66, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 13717.01, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 24889.8, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3747.14, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 24889.8, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Cystouretero w/lithotripsy", "code_information": [ { "code": "52353", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 3747.14, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2775.66, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 12571.05, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 22810.38, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3747.14, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 22810.38, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Cystouretero w/renal strict", "code_information": [ { "code": "52346", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 3747.14, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2775.66, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 24132.07, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 43788.03, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3747.14, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 43788.03, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Cystouretero w/stone remove", "code_information": [ { "code": "52352", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2542.24, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1883.14, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 12689.94, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 23125.12, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2542.24, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 23125.12, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Cystourethro cut ejacul duct", "code_information": [ { "code": "52402", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2542.24, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1883.14, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 8723.19, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 15828.36, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2542.24, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 15828.36, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Cystourethro w/implant", "code_information": [ { "code": "52441", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 20583.13, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 37348.43, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 37348.43, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Cystureth blu li cyst fl img", "code_information": [ { "code": "C7554", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 12142.28, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 22032.36, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 22032.36, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CYTARABINE (PF) 100 MG/ML IJ SOLN", "drug_information": { "unit": "20.000000", "type": "UN" }, "code_information": [ { "code": "61703031922", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.65, "maximum": 38.87, "gross_charge": 41.35, "discounted_cash": 22.74, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.98, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.58, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.08, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.02, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.03, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.85, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.77, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.73, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.87, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.39, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.65, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.15, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.01, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.57, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.12, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.87, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.38, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.58, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.87, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.01, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.39, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.98, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.58, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CYTARABINE (PF) 20 MG/ML IJ SOLN", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "61703030538", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "CYTARABINE CHEMO SYR", "drug_information": { "unit": "20.000000", "type": "UN" }, "code_information": [ { "code": "61703031922_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.38, "maximum": 104.67, "gross_charge": 111.35, "discounted_cash": 61.24, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 64.58, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.8, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 89.08, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 94.31, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.4, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 53.45, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 66.7, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 66.59, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 104.67, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 97.99, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.38, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 94.65, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 83.51, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.23, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 104.67, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.19, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.8, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.52, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 83.51, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 97.99, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 64.58, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.8, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "D & c after delivery", "code_information": [ { "code": "59160", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2343.63, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1736.02, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 5655.39, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 10269.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2343.63, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 10269.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DABIGATRAN ETEXILATE MESYLATE 150 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00597036082", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.0, "maximum": 6.68, "gross_charge": 7.11, "discounted_cash": 3.91, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.12, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.88, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.69, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.02, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.07, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.41, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.26, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.25, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.68, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.26, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.04, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.33, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.5, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.83, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.68, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.57, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.88, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.65, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.33, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.26, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.12, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.88, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DABIGATRAN ETEXILATE MESYLATE 75 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00597035556", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.0, "maximum": 6.68, "gross_charge": 7.11, "discounted_cash": 3.91, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.12, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.88, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.69, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.02, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.07, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.41, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.26, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.25, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.68, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.26, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.04, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.33, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.5, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.83, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.68, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.57, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.88, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.65, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.33, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.26, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.12, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.88, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DACARBAZINE 200 MG IV SOLR", "drug_information": { "unit": "20.000000", "type": "UN" }, "code_information": [ { "code": "00143924510", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DACTINOMYCIN 0.5 MG IV SOLR", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "42658000801", "type": "NDC" } ], "standard_charges": [ { "minimum": 154.04, "maximum": 1702.68, "gross_charge": 1811.36, "discounted_cash": 996.25, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1050.59, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 154.04, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1449.09, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { 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"standard_charge_dollar": 1358.52, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 638.14, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1231.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1702.68, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1418.29, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 207.96, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1440.03, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1358.52, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1594.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1050.59, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 154.04, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "DAILY VITES PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00904053061", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DAKINS (1/2 STRENGTH) 0.25 % EX SOLN", "drug_information": { "unit": "473.000000", "type": "UN" }, "code_information": [ { "code": "00436093616", "type": "NDC" } ], "standard_charges": [ { "minimum": 8.78, "maximum": 29.28, "gross_charge": 31.15, "discounted_cash": 17.13, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.07, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.01, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.92, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.38, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.06, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.95, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.66, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.63, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.28, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.41, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.78, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.48, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.36, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.97, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.18, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.28, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.39, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.01, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.76, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.36, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.41, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.07, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.01, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DAKINS (1/4 STRENGTH) 0.125 % EX SOLN", "drug_information": { "unit": "473.000000", "type": "UN" }, "code_information": [ { "code": "00436067216", "type": "NDC" } ], "standard_charges": [ { "minimum": 8.78, "maximum": 29.28, "gross_charge": 31.15, "discounted_cash": 17.13, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.07, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.01, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.92, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.38, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.06, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.95, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.66, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.63, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.28, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.41, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.78, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.48, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.36, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.97, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.18, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.28, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.39, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.01, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.76, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.36, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.41, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.07, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.01, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DAKINS (FULL STRENGTH) 0.5 % EX SOLN", "drug_information": { "unit": "473.000000", "type": "UN" }, "code_information": [ { "code": "00436094616", "type": "NDC" } ], "standard_charges": [ { "minimum": 8.78, "maximum": 29.28, "gross_charge": 31.15, "discounted_cash": 17.13, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.07, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.01, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.92, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.38, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.06, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.95, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.66, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.63, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.28, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.41, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.78, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.48, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.36, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.97, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.18, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.28, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.39, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.01, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.76, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.36, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.41, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.07, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.01, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DAKINS 0.125% (QUARTER STRENGTH)EX SOLN", "drug_information": { "unit": "1000.000000", "type": "UN" }, "code_information": [ { "code": "C0436067216", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DALBAVANCIN HCL 500 MG IV SOLR", "drug_information": { "unit": "25.000000", "type": "UN" }, "code_information": [ { "code": "57970010001", "type": "NDC" } ], "standard_charges": [ { "minimum": 1294.13, "maximum": 4316.83, "gross_charge": 4592.37, "discounted_cash": 2525.8, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2663.57, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2507.43, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3673.9, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3889.74, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1336.38, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2204.34, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2750.83, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2746.24, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4316.83, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4041.29, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1294.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3903.51, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3444.28, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1617.89, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3122.81, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4316.83, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3595.83, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2507.43, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3650.93, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3444.28, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4041.29, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2663.57, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2507.43, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DANAZOL 100 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00527136801", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DANAZOL 200 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00527136906", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.07, "maximum": 6.91, "gross_charge": 7.35, "discounted_cash": 4.04, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.26, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.01, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.88, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.23, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.14, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.53, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.91, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.47, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.07, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.25, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.51, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.59, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.0, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.91, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.76, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.01, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.84, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.51, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.47, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.26, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.01, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DANAZOL 50 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00555063302", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.62, "maximum": 5.41, "gross_charge": 5.75, "discounted_cash": 3.16, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.34, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.14, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.6, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.87, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.67, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.76, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.44, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.44, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.41, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.06, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.62, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.89, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.31, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.03, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.91, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.41, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.5, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.14, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.57, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.31, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.06, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.34, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.14, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DANTROLENE SODIUM 100 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00115443301", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DANTROLENE SODIUM 25 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68084030021", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DANTROLENE SODIUM 250 MG IV SUSR", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "42367054032", "type": "NDC" } ], "standard_charges": [ { "minimum": 1982.51, "maximum": 6613.07, "gross_charge": 7035.18, "discounted_cash": 3869.35, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4080.4, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3841.21, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5628.14, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5958.8, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2047.24, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3376.89, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4214.07, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4207.04, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6613.07, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6190.96, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1982.51, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5979.9, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5276.39, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2478.49, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4783.92, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6613.07, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5508.55, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3841.21, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5592.97, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5276.39, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6190.96, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4080.4, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3841.21, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DAPAGLIFLOZIN PROPANEDIOL 10 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00310621039", "type": "NDC" } ], "standard_charges": [ { "minimum": 8.4, "maximum": 28.03, "gross_charge": 29.82, "discounted_cash": 16.4, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.3, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.28, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.86, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.26, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.68, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.31, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.86, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.83, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.03, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.24, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.4, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.35, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.37, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.51, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.28, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.03, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.35, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.28, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.71, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.37, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.24, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.3, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.28, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DAPAGLIFLOZIN PROPANEDIOL 5 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "5009070560", "type": "NDC" } ], "standard_charges": [ { "minimum": 6.18, "maximum": 20.6, "gross_charge": 21.92, "discounted_cash": 12.06, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.71, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.97, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.54, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.57, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.38, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.52, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.13, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.11, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.29, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.18, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.63, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.44, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.72, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.91, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.16, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.97, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.43, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.44, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.29, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.71, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.97, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DAPSONE 0.0002 MG/ML SUSPENSION FOR DESENSITIZATION", "drug_information": { "unit": "0.500000", "type": "UN" }, "code_information": [ { "code": "P4993810230", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DAPSONE 100 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "R7095413620", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DAPSONE 25 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "R7095413510", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DAPTOMYCIN 1000 MG/100 ML RTU", "drug_information": { "unit": "100.000000", "type": "UN" }, "code_information": [ { "code": "00338071812", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DAPTOMYCIN 350 MG/50 ML RTU", "drug_information": { "unit": "100.000000", "type": "UN" }, "code_information": [ { "code": "00338071224", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DAPTOMYCIN 500 MG IV SOLR", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "43598041311", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DAPTOMYCIN 500 MG/50 ML RTU", "drug_information": { "unit": "100.000000", "type": "UN" }, "code_information": [ { "code": "00338071424", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DAPTOMYCIN 700 MG/100 ML RTU", "drug_information": { "unit": "100.000000", "type": "UN" }, "code_information": [ { "code": "00338071612", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DARATUMUMAB 100 MG/5ML IV SOLN", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "57894050505", "type": "NDC" } ], "standard_charges": [ { "minimum": 35.56, "maximum": 2751.0, "gross_charge": 2926.6, "discounted_cash": 1609.63, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1697.43, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2341.28, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2478.83, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 851.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1404.77, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1753.03, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 1750.11, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2751.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2575.41, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 824.72, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2487.61, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2194.95, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1031.04, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1990.09, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2751.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2291.53, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 48.0, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2326.65, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2194.95, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2575.41, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1697.43, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "DARATUMUMAB-HYALURONIDASE-FIHJ 1800-30000 MG-UT/15ML SC SOLN", "drug_information": { "unit": "15.000000", "type": "UN" }, "code_information": [ { "code": "57894050301", "type": "NDC" } ], "standard_charges": [ { "minimum": 8430.77, "maximum": 28122.51, "gross_charge": 29917.56, "discounted_cash": 16454.66, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 17352.18, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 16334.99, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23934.05, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 25340.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8706.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14360.43, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 17920.62, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 11394.0, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 28122.51, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 26327.45, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 8430.77, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 25429.93, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 22438.17, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 10539.96, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 20343.94, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 28122.51, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23425.45, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 16334.99, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 15189.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 22438.17, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 26327.45, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 17352.18, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 16334.99, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DARBEPOETIN ALFA 100 MCG/0.5ML IJ SOSY", "drug_information": { "unit": "0.500000", "type": "UN" }, "code_information": [ { "code": "55513002504", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.66, "maximum": 2820.11, "gross_charge": 3000.12, "discounted_cash": 1650.07, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1740.07, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.66, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2400.1, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2541.1, "standard_charge_percentage": 85.0, 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"standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2640.11, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 845.43, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2550.1, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2250.09, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", 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schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2385.1, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2250.09, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2640.11, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1740.07, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.66, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "DARBEPOETIN ALFA 100 MCG/ML IJ SOLN", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "55513000504", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.66, "maximum": 2820.11, "gross_charge": 3000.12, "discounted_cash": 1650.07, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1740.07, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.66, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", 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"additional_payer_notes": "N/A", "standard_charge_dollar": 1794.07, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2820.11, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2640.11, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 845.43, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2550.1, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2250.09, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1056.94, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2040.08, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2820.11, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2349.09, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.24, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2385.1, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2250.09, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2640.11, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1740.07, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.66, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "DARBEPOETIN ALFA 200 MCG/0.4ML IJ SOSY", "drug_information": { "unit": "0.400000", "type": "UN" }, "code_information": [ { "code": "55513002801", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.66, "maximum": 4230.17, "gross_charge": 4500.18, "discounted_cash": 2475.1, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2610.1, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.66, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3600.14, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3811.65, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1309.55, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2160.09, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2695.61, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2691.11, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4230.17, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3960.16, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1268.15, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3825.15, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3375.14, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1585.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3060.12, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4230.17, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3523.64, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.24, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3577.64, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3375.14, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3960.16, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2610.1, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.66, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "DARBEPOETIN ALFA 200 MCG/ML IJ SOLN", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "55513000601", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.66, "maximum": 4230.17, "gross_charge": 4500.18, "discounted_cash": 2475.1, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2610.1, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.66, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3600.14, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3811.65, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1309.55, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2160.09, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2695.61, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2691.11, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4230.17, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3960.16, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1268.15, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3825.15, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3375.14, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1585.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3060.12, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4230.17, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3523.64, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.24, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3577.64, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3375.14, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3960.16, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2610.1, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.66, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "DARBEPOETIN ALFA 25 MCG/ML IJ SOLN", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "55513000204", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.66, "maximum": 616.91, "gross_charge": 656.29, "discounted_cash": 360.96, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 380.65, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.66, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 525.03, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 555.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 190.98, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 315.02, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 393.12, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 392.46, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care 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"methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 231.21, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 446.28, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 616.91, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 513.88, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": 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"Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.66, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "DARBEPOETIN ALFA 300 MCG/0.6ML IJ SOSY", "drug_information": { "unit": "0.600000", "type": "UN" }, "code_information": [ { "code": "55513011101", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.66, "maximum": 6345.25, "gross_charge": 6750.27, "discounted_cash": 3712.65, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3915.16, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.66, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5400.22, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5717.48, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1964.33, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3240.13, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4043.41, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4036.66, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6345.25, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5940.24, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1902.23, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5737.73, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5062.7, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2378.12, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4590.18, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6345.25, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5285.46, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.24, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5366.46, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5062.7, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5940.24, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3915.16, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.66, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "DARBEPOETIN ALFA 40 MCG/0.4ML IJ SOSY", "drug_information": { "unit": "0.400000", "type": "UN" }, "code_information": [ { "code": "55513002104", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.66, "maximum": 1128.05, "gross_charge": 1200.05, "discounted_cash": 660.03, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 696.03, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.66, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 960.04, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1016.44, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 349.21, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 576.02, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 718.83, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 717.63, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1128.05, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1056.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 338.17, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1020.04, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 900.04, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 422.78, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 816.03, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1128.05, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 939.64, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.24, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 954.04, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 900.04, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1056.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 696.03, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.66, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "DARBEPOETIN ALFA 40 MCG/ML IJ SOLN", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "55513000304", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.66, "maximum": 1128.05, "gross_charge": 1200.05, "discounted_cash": 660.03, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 696.03, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.66, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 960.04, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1016.44, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 349.21, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 576.02, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 718.83, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 717.63, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1128.05, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1056.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 338.17, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1020.04, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 900.04, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 422.78, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 816.03, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1128.05, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 939.64, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.24, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 954.04, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 900.04, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1056.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 696.03, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.66, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "DARBEPOETIN ALFA 500 MCG/ML IJ SOSY", "drug_information": { "unit": "0.300000", "type": "UN" }, "code_information": [ { "code": "55513003201", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.66, "maximum": 10575.42, "gross_charge": 11250.45, "discounted_cash": 6187.75, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 6525.26, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.66, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9000.36, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", 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"additional_payer_notes": "N/A", "standard_charge_dollar": 1.66, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "DARBEPOETIN ALFA 60 MCG/0.3ML IJ SOSY", "drug_information": { "unit": "0.300000", "type": "UN" }, "code_information": [ { "code": "55513002304", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.66, "maximum": 1692.07, "gross_charge": 1800.07, "discounted_cash": 990.04, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1044.04, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.66, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", 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"methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1350.05, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 634.16, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1224.05, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1692.07, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1409.45, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.24, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1431.06, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1350.05, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1584.06, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", 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Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.66, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1440.06, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1524.66, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 523.82, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 864.03, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1078.24, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 1076.44, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1692.07, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1584.06, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 507.26, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1530.06, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1350.05, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 634.16, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1224.05, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1692.07, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1409.45, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.24, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1431.06, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1350.05, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1584.06, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1044.04, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.66, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "DARUNAVIR 100 MG/ML PO SUSP", "drug_information": { "unit": "6.000000", "type": "UN" }, "code_information": [ { "code": "59676056501", "type": "NDC" } ], "standard_charges": [ { "minimum": 25.34, "maximum": 84.52, "gross_charge": 89.92, "discounted_cash": 49.46, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.15, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.1, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 71.94, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 76.16, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.17, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.16, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 53.86, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 53.77, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 84.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 79.13, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.34, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 76.43, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 67.44, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.68, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.15, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 84.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 70.41, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.1, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 71.49, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 67.44, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 79.13, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.15, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.1, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DARUNAVIR 600 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00480773606", "type": "NDC" } ], "standard_charges": [ { "minimum": 7.47, "maximum": 24.91, "gross_charge": 26.5, "discounted_cash": 14.58, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.37, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.47, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.45, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.71, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.72, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.87, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.85, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - 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"methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.34, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.02, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.91, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.75, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.47, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.07, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.88, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.32, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.37, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.47, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DARUNAVIR 800 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687081921", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.48, "maximum": 8.26, "gross_charge": 8.79, "discounted_cash": 4.83, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.1, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.8, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.03, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.45, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.56, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.22, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.27, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.26, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.26, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.74, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.48, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.47, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.59, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.1, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.98, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.26, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.88, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.8, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.99, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.59, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.74, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.1, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.8, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DARUNAVIR-COBICISTAT 800-150 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "59676057530", "type": "NDC" } ], "standard_charges": [ { "minimum": 62.96, "maximum": 210.01, "gross_charge": 223.41, "discounted_cash": 122.88, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 129.58, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 121.98, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 178.73, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 189.23, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 107.24, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 133.82, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 133.6, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 210.01, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 196.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 62.96, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 189.9, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 167.56, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 78.71, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 151.92, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 210.01, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 174.93, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 121.98, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 177.61, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 167.56, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 196.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 129.58, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 121.98, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DASATINIB 100 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00003085222", "type": "NDC" } ], "standard_charges": [ { "minimum": 665.01, "maximum": 2218.27, "gross_charge": 2359.86, "discounted_cash": 1297.92, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1368.72, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1288.48, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1887.89, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1998.8, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 686.72, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1132.73, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1413.56, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 1411.2, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2218.27, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2076.68, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 665.01, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2005.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1769.9, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 831.38, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1604.7, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2218.27, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1847.77, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1288.48, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1876.09, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1769.9, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2076.68, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1368.72, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1288.48, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DASATINIB 20 MG PO TABS", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "00003052711", "type": "NDC" } ], "standard_charges": [ { "minimum": 807.12, "maximum": 2692.32, "gross_charge": 2864.17, "discounted_cash": 1575.29, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1661.22, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1563.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2291.34, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2425.95, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 833.47, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1374.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1715.64, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 1712.77, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2692.32, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2520.47, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 807.12, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2434.54, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2148.13, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1009.05, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1947.64, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2692.32, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2242.65, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1563.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2277.02, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2148.13, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2520.47, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1661.22, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1563.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DASATINIB 50 MG PO TABS", "drug_information": { "unit": "2.000000", "type": "UN" }, "code_information": [ { "code": "00003052811", "type": "NDC" } ], "standard_charges": [ { "minimum": 689.03, "maximum": 2298.38, "gross_charge": 2445.09, "discounted_cash": 1344.8, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1418.15, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1335.02, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1956.07, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2070.99, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 711.52, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1173.64, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1464.61, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 1462.16, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2298.38, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2151.68, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 689.03, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2078.33, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1833.82, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 861.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1662.66, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2298.38, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1914.51, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1335.02, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1943.85, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1833.82, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2151.68, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1418.15, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1335.02, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DASATINIB 70 MG PO TABS", "drug_information": { "unit": "2.000000", "type": "UN" }, "code_information": [ { "code": "00003052411", "type": "NDC" } ], "standard_charges": [ { "minimum": 737.94, "maximum": 2461.55, "gross_charge": 2618.67, "discounted_cash": 1440.27, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1518.83, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1429.79, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2094.94, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2218.01, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 762.03, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1256.96, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1568.58, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 1565.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2461.55, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2304.43, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 737.94, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2225.87, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1964.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 922.56, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1780.7, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2461.55, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2050.42, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1429.79, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2081.84, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1964.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2304.43, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1518.83, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1429.79, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DAUNORUBICIN CHEMO SYR", "drug_information": { "unit": "4.000000", "type": "UN" }, "code_information": [ { "code": "42658002102_3", "type": "NDC" } ], "standard_charges": [ { "minimum": 13.34, "maximum": 137.4, "gross_charge": 146.17, "discounted_cash": 80.39, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 84.78, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.34, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 116.94, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 123.81, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.54, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 70.16, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.56, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.41, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 137.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 128.63, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.19, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 124.24, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 109.63, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 51.5, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 99.4, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 137.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 114.45, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.01, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 116.21, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 109.63, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 128.63, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 84.78, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.34, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "DAUNORUBICIN CHEMO SYR|DISCARDED DRUG NOT ADMINISTERED", "drug_information": { "unit": "4.000000", "type": "UN" }, "code_information": [ { "code": "42658002102", "type": "NDC" } ], "standard_charges": [ { "minimum": 13.34, "maximum": 71.6, "gross_charge": 76.17, "discounted_cash": 41.89, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 44.18, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.34, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.94, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 64.52, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.17, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.56, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.63, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.55, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 71.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 67.03, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.46, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 64.74, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 57.13, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.83, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 51.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 71.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.64, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.01, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.56, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 57.13, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 67.03, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 44.18, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.34, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "DAUNORUBICIN HCL 20 MG/4ML IV SOLN", "drug_information": { "unit": "4.000000", "type": "UN" }, "code_information": [ { "code": "42658002102_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 13.34, "maximum": 71.6, "gross_charge": 76.17, "discounted_cash": 41.89, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 44.18, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.34, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.94, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 64.52, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.17, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.56, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.63, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.55, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 71.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 67.03, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.46, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 64.74, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 57.13, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.83, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 51.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 71.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.64, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.01, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.56, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 57.13, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 67.03, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 44.18, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.34, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "DAUNORUBICIN-CYTARABINE LIPO 44-100 MG IV SUSR", "drug_information": { "unit": "20.000000", "type": "UN" }, "code_information": [ { "code": "68727074502", "type": "NDC" } ], "standard_charges": [ { "minimum": 8293.37, "maximum": 27664.2, "gross_charge": 29430.0, "discounted_cash": 16186.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 17069.4, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 16068.78, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23544.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 24927.21, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8564.13, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14126.4, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 17628.57, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 11394.0, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 27664.2, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 25898.4, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 8293.37, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 25015.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 22072.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 10368.19, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 20012.4, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27664.2, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23043.69, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 16068.78, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 15189.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 22072.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 25898.4, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 17069.4, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 16068.78, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Dbrdmt bone 1st 20 sq cm/<", "code_information": [ { "code": "11044", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1194.28, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 884.65, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 5752.19, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 10437.44, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1194.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 10437.44, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Dbrdmt musc&/fsca 1st 20/<", "code_information": [ { "code": "11043", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 451.2, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 1567.36, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 2844.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 451.2, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 2844.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Dbrdmt skin abdominal wall", "code_information": [ { "code": "11005", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 14384.59, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 26590.48, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 26590.48, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Dbrdmt subq tis 1st 20sqcm/<", "code_information": [ { "code": "11042", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 294.49, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 709.28, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 1287.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 294.49, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 1287.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Deb skin bone at fx site", "code_information": [ { "code": "11012", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2109.62, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1562.68, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 21786.22, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 39531.45, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2109.62, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 39531.45, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DECITABINE 50 MG IV SOLR", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "71288011920", "type": "NDC" } ], "standard_charges": [ { "minimum": 17.65, "maximum": 58.87, "gross_charge": 62.63, "discounted_cash": 34.45, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.33, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.2, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.1, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 53.05, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.23, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.06, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.52, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.45, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 58.87, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.11, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.65, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 53.24, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.97, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.06, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.59, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 58.87, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.04, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.2, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.79, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.97, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.11, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.33, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.2, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Decompress eye socket", "code_information": [ { "code": "61330", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2390.47, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1770.72, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 9560.27, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 17347.27, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2390.47, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 17347.27, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Decompress fingers/hand", "code_information": [ { "code": "26037", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2391.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1771.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 7770.82, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 14100.3, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2391.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 14100.3, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Decompress forearm 1 space", "code_information": [ { "code": "25020", "type": "HCPCS" }, { "code": "25023", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2391.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 873.82, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1771.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 6534.54, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 11857.05, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1179.66, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2391.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 11857.05, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Decompress optic nerve", "code_information": [ { "code": "67570", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2779.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2058.97, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 13264.47, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 24068.61, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2779.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 24068.61, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Decompress spinal cord lmbr", "code_information": [ { "code": "63056", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 5265.64, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3900.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 15042.97, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 27405.24, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5265.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 27405.24, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Decompression of lower leg", "code_information": [ { "code": "27600", "type": "HCPCS" }, { "code": "27601", "type": "HCPCS" }, { "code": "27602", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2391.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1771.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 15620.66, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 28343.95, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2391.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 28343.95, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Decompression of tibia nerve", "code_information": [ { "code": "28035", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1439.39, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1066.21, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 7199.44, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 13071.28, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1439.39, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 13071.28, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Deep muscle biopsy", "code_information": [ { "code": "20205", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2109.62, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1562.68, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 10311.84, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 18711.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2109.62, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 18711.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DEFERASIROX 125 MG PO TBSO", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68462049430", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DEFERASIROX 250 MG PO TBSO", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "45963045530", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.94, "maximum": 106.56, "gross_charge": 113.36, "discounted_cash": 62.35, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.75, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.89, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 90.69, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.02, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.99, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.41, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 67.9, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 67.79, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 106.56, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 99.76, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.94, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.36, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 85.02, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.94, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 77.08, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 106.56, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.76, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.89, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 90.12, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 85.02, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 99.76, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.75, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.89, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DEFERASIROX 360 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "31722001330", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DEFERASIROX 500 MG PO TBSO", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "69452016113", "type": "NDC" } ], "standard_charges": [ { "minimum": 6.17, "maximum": 20.59, "gross_charge": 21.9, "discounted_cash": 12.05, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.7, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.96, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.52, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.55, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.37, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.51, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.12, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.1, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.59, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.27, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.17, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.62, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.43, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.72, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.89, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.59, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.15, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.96, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.41, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.43, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.27, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.7, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.96, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DEFERIPRONE 1000 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00054071119", "type": "NDC" } ], "standard_charges": [ { "minimum": 107.12, "maximum": 357.33, "gross_charge": 380.14, "discounted_cash": 209.08, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 220.48, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 207.56, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 304.11, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 321.98, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 110.62, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 182.47, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 227.7, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 227.32, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 357.33, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 334.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 107.12, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 323.12, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 285.11, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 133.92, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 258.5, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 357.33, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 297.65, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 207.56, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 302.21, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 285.11, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 334.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 220.48, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 207.56, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DEFEROXAMINE MESYLATE 2 G IJ SOLR", "drug_information": { "unit": "21.050000", "type": "UN" }, "code_information": [ { "code": "00409233725", "type": "NDC" } ], "standard_charges": [ { "minimum": 22.43, "maximum": 74.82, "gross_charge": 79.6, "discounted_cash": 43.78, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.17, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.46, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.68, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 67.42, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.21, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.68, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.6, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.82, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 70.05, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.43, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 67.66, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.7, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.04, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.13, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.82, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 62.33, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.46, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.28, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.7, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 70.05, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.17, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.46, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DEFEROXAMINE MESYLATE 500 MG IJ SOLR", "drug_information": { "unit": "5.270000", "type": "UN" }, "code_information": [ { "code": "63323059710", "type": "NDC" } ], "standard_charges": [ { "minimum": 16.51, "maximum": 55.08, "gross_charge": 58.6, "discounted_cash": 32.23, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.99, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.88, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.63, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.05, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.13, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.1, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.04, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.08, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 51.57, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.51, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.81, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.95, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.64, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.85, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.08, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.88, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.59, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.95, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 51.57, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.99, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DEFIBROTIDE SODIUM 200 MG/2.5ML IV SOLN", "drug_information": { "unit": "2.500000", "type": "UN" }, "code_information": [ { "code": "68727080002", "type": "NDC" } ], "standard_charges": [ { "minimum": 1126.07, "maximum": 3756.24, "gross_charge": 3996.0, "discounted_cash": 2197.8, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2317.68, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2181.82, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3196.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3384.61, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1162.84, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1918.08, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2393.6, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2389.61, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3756.24, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3516.48, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1126.07, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3396.6, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2997.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1407.79, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2717.28, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3756.24, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3128.87, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2181.82, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3176.82, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2997.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3516.48, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2317.68, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2181.82, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DEGARELIX ACETATE 80 MG SC SOLR", "drug_information": { "unit": "4.000000", "type": "UN" }, "code_information": [ { "code": "55566830301", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.28, "maximum": 1663.39, "gross_charge": 1769.56, "discounted_cash": 973.26, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1026.34, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1415.65, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1498.82, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 514.94, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 849.39, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1059.97, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 1058.2, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1663.39, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1557.21, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 498.66, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1504.13, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1327.17, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 623.42, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1203.3, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1663.39, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1385.57, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.08, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1406.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1327.17, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1557.21, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1026.34, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "DEGARELIX ACETATE(240 MG DOSE) 120 MG/VIAL SC SOLR", "drug_information": { "unit": "6.000000", "type": "UN" }, "code_information": [ { "code": "55566840301", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.28, "maximum": 3892.87, "gross_charge": 4141.35, "discounted_cash": 2277.74, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2401.98, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3313.08, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3507.72, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1205.13, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1987.85, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2480.67, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2476.53, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3892.87, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3644.39, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1167.03, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3520.15, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3106.01, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1459.0, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2816.12, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3892.87, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3242.68, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.08, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3292.37, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3106.01, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3644.39, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2401.98, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "DEKAS PLUS PO CHEW", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "6817600015", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", 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{ "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DEKAS PLUS PO LIQD", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68176000010", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DELANDISTROGENE MOXEPARVO-ROKL 15 X 10 ML IV KIT", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60923050615", "type": "NDC" } ], "standard_charges": [ { "minimum": 11394.0, "maximum": 9024000.0, "gross_charge": 9600000.0, "discounted_cash": 5280000.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5568000.0, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5241600.0, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7680000.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8131200.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2793600.0, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4608000.0, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5750400.0, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 11394.0, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9024000.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8448000.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2705280.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8160000.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7200000.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3382080.0, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6528000.0, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 9024000.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7516800.0, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5241600.0, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 15189.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7200000.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8448000.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5568000.0, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5241600.0, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DELANDISTROGENE MOXEPARVO-ROKL 18 X 10 ML IV KIT", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60923050918", "type": "NDC" } ], "standard_charges": [ { "minimum": 11394.0, "maximum": 9024000.0, "gross_charge": 9600000.0, "discounted_cash": 5280000.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5568000.0, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1815698.3, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7680000.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8131200.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2793600.0, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4608000.0, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5750400.0, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 11394.0, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9024000.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8448000.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2705280.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8160000.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7200000.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3382080.0, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6528000.0, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", 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} ], "additional_generic_notes": "" } ] }, { "description": "DELANDISTROGENE MOXEPARVO-ROKL 22 X 10 ML IV KIT", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60923051322", "type": "NDC" } ], "standard_charges": [ { "minimum": 11394.0, "maximum": 9024000.0, "gross_charge": 9600000.0, "discounted_cash": 5280000.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5568000.0, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1815698.3, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7680000.0, 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"N/A", "standard_charge_dollar": 9024000.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8448000.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2705280.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8160000.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7200000.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed 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"additional_payer_notes": "N/A", "standard_charge_dollar": 1815698.3, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7680000.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8131200.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2793600.0, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4608000.0, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { 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"additional_generic_notes": "" } ] }, { "description": "DELANDISTROGENE MOXEPARVO-ROKL 47 X 10 ML IV KIT", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60923053847", "type": "NDC" } ], "standard_charges": [ { "minimum": 11394.0, "maximum": 9024000.0, "gross_charge": 9600000.0, "discounted_cash": 5280000.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5568000.0, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1815698.3, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7680000.0, 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48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5750400.0, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 11394.0, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9024000.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8448000.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": 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billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 9024000.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7516800.0, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2451192.7, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 15189.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7200000.0, 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"standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 13852.08, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Delay flap eye/nos/ear/lip", "code_information": [ { "code": "15630", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1348.33, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 998.76, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 6107.85, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", 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998.76, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 7041.32, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 12776.58, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1348.33, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 12776.58, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Delay flap trunk", "code_information": [ { "code": "15600", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2698.5, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1998.89, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 9570.13, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 17365.15, "methodology": "percent of total billed charges" }, { "payer_name": 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"payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.73, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.86, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.44, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.59, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.37, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.59, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.85, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.47, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.48, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.25, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.34, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.38, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.59, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.65, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.73, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.25, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.85, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.15, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.73, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DENOSUMAB 120 MG/1.7ML SC SOLN", "drug_information": { "unit": "1.700000", "type": "UN" }, "code_information": [ { "code": "55513073001", "type": "NDC" } ], "standard_charges": [ { "minimum": 2693.94, "maximum": 8986.18, "gross_charge": 9559.77, "discounted_cash": 5257.87, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5544.67, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5219.63, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7647.82, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8097.13, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2781.89, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4588.69, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5726.3, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 5716.74, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8986.18, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8412.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2693.94, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8125.8, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7169.83, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3367.91, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6500.64, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 8986.18, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7485.3, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5219.63, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7600.02, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7169.83, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8412.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5544.67, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5219.63, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DENOSUMAB 60 MG/ML SC SOSY", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "55513071021", "type": "NDC" } ], "standard_charges": [ { "minimum": 14.72, "maximum": 4561.89, "gross_charge": 4853.07, "discounted_cash": 2669.19, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2814.78, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.72, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3882.46, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4110.55, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1412.24, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2329.47, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2906.99, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2902.14, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4561.89, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4270.7, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1367.6, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4125.11, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3639.8, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1709.74, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3300.09, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4561.89, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3799.95, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.87, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3858.19, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3639.8, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4270.7, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2814.78, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.72, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "Derm autograft face/nck/hf/g", "code_information": [ { "code": "15135", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2698.5, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1998.89, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 42165.2, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 76509.46, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2698.5, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 76509.46, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Derma-fat-fascia graft", "code_information": [ { "code": "15770", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2698.5, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1998.89, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 43215.32, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 78414.92, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2698.5, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 78414.92, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DERMABOND HV SKIN ADHESIVE", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "C4444114575", "type": "NDC" } ], "standard_charges": [ { "minimum": 17.71, "maximum": 1158.0, "gross_charge": 62.83, "discounted_cash": 34.56, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.44, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.31, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.54, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.28, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.16, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.64, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.57, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.06, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.29, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.71, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 53.41, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.12, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.14, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.06, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.2, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.31, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.95, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.12, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.29, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.44, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.31, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DERMABOND MINI SKIN ADHESIVE", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "C8252114512", "type": "NDC" } ], "standard_charges": [ { "minimum": 8.75, "maximum": 1158.0, "gross_charge": 31.06, "discounted_cash": 17.08, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.01, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.96, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.96, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.04, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.91, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.6, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.57, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.2, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.33, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.75, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.3, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.94, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.12, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.2, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.96, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.69, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.3, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.33, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.01, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.96, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DESFLURANE IN SOLN", "drug_information": { "unit": "240.000000", "type": "UN" }, "code_information": [ { "code": "10019064134", "type": "NDC" } ], "standard_charges": [ { "minimum": 82.12, "maximum": 273.93, "gross_charge": 291.41, "discounted_cash": 160.28, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 169.02, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 159.11, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 233.13, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 246.82, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 84.8, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 139.88, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 174.55, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 174.26, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 273.93, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 256.44, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.12, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 247.7, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 218.56, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 102.66, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 198.16, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 273.93, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 228.17, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 159.11, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 231.67, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 218.56, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 256.44, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 169.02, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 159.11, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DESIPRAMINE HCL 10 MG PO TABS", "drug_information": { "unit": "3.000000", "type": "UN" }, "code_information": [ { "code": "R5074211201", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DESIPRAMINE HCL 25 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "50742011301", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DESIPRAMINE HCL 50 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "50742011401", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DESMOPRESSIN ACE SPRAY REFRIG 0.01 % NA SOLN", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "24208034205", "type": "NDC" } ], "standard_charges": [ { "minimum": 108.05, "maximum": 360.42, "gross_charge": 383.43, "discounted_cash": 210.89, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 222.39, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 209.35, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 306.74, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 324.77, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 111.58, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 184.05, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 229.67, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 229.29, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 360.42, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 337.42, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 108.05, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 325.92, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 287.57, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 135.08, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 260.73, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 360.42, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 300.23, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 209.35, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 304.83, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 287.57, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 337.42, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 222.39, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 209.35, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DESMOPRESSIN ACETATE 0.1 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687072121", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DESMOPRESSIN ACETATE 0.2 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687073221", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DESMOPRESSIN ACETATE 4 MCG/ML IJ SOLN", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "39822625001", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.96, "maximum": 432.08, "gross_charge": 459.66, "discounted_cash": 252.81, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 266.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.96, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 367.73, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 389.33, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 133.76, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 220.64, "standard_charge_percentage": 48.0, "methodology": "percent of total billed 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charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.38, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.68, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.13, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.96, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "DESMOPRESSIN ACETATE PF 4 MCG/ML IJ SOLN", "drug_information": { "unit": "1.000000", "type": "UN" }, 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"standard_charge_dollar": 45.59, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.68, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.67, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.23, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.38, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": 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"standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "DESMOPRESSIN ACETATE SPRAY 0.01 % NA SOLN", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "60505081500", "type": "NDC" } ], "standard_charges": [ { "minimum": 32.02, "maximum": 106.81, "gross_charge": 113.63, "discounted_cash": 62.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.91, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 62.04, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 90.9, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.24, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.07, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.54, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 68.06, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 67.95, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 106.81, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 99.99, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.02, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.59, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 85.22, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.03, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 77.27, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 106.81, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.97, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 62.04, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 90.34, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 85.22, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 99.99, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.91, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 62.04, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DESOGESTREL-ETHINYL ESTRADIOL 0.15-0.02/0.01 MG (21/5) PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00555905058", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": 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"percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DESOGESTREL-ETHINYL ESTRADIOL 0.15-30 MG-MCG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "70700011385", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 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"standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DESONIDE 0.05 % EX CREA", "drug_information": { "unit": "15.000000", "type": "GR" }, "code_information": [ { "code": "51672128001", "type": "NDC" } ], "standard_charges": [ { "minimum": 12.34, "maximum": 41.17, "gross_charge": 43.8, "discounted_cash": 24.09, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.4, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.91, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.04, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": 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"additional_payer_notes": "N/A", "standard_charge_dollar": 41.17, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.54, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.34, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.23, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.85, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.43, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.78, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.17, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.3, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.91, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.82, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.85, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.54, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.4, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.91, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DESONIDE 0.05 % EX GEL", "drug_information": { "unit": "60.000000", "type": "GR" }, "code_information": [ { "code": "24470092060", "type": "NDC" } ], "standard_charges": [ { "minimum": 259.55, "maximum": 865.77, "gross_charge": 921.03, "discounted_cash": 506.57, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 534.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 502.88, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 736.82, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 780.11, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 268.02, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 442.09, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 551.7, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 550.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 865.77, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 810.51, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 259.55, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 782.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 690.77, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 324.48, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 626.3, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 865.77, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 721.17, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 502.88, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 732.22, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 690.77, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 810.51, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 534.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 502.88, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DESONIDE 0.05 % EX LOTN", "drug_information": { "unit": "59.000000", "type": "UN" }, "code_information": [ { "code": "00472080302", "type": "NDC" } ], "standard_charges": [ { "minimum": 74.59, "maximum": 248.8, "gross_charge": 264.68, "discounted_cash": 145.57, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 153.51, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 144.52, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 211.74, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 224.18, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 77.02, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 127.05, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 158.54, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 158.28, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 248.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 232.92, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.59, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 224.98, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 198.51, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.25, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 179.98, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 248.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 207.24, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 144.52, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 210.42, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 198.51, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 232.92, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 153.51, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 144.52, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DESONIDE 0.05 % EX OINT", "drug_information": { "unit": "15.000000", "type": "GR" }, "code_information": [ { "code": "21922000404", "type": "NDC" } ], "standard_charges": [ { "minimum": 9.46, "maximum": 31.57, "gross_charge": 33.58, "discounted_cash": 18.47, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.48, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.33, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.86, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.44, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.77, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.12, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.11, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.08, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.57, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.55, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.46, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.54, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.19, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.83, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.83, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.57, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.29, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.33, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.7, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.19, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.55, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.48, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.33, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DESOXIMETASONE 0.05 % EX CREA", "drug_information": { "unit": "60.000000", "type": "GR" }, "code_information": [ { "code": "51672127103", "type": "NDC" } ], "standard_charges": [ { "minimum": 187.24, "maximum": 624.56, "gross_charge": 664.43, "discounted_cash": 365.44, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 385.37, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 362.78, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 531.54, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 562.77, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 193.35, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 318.93, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 397.99, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 397.33, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 624.56, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 584.7, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 187.24, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 564.77, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 498.32, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 234.08, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 451.81, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 624.56, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 520.25, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 362.78, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 528.22, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 498.32, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 584.7, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 385.37, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 362.78, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DESOXIMETASONE 0.05 % EX OINT", "drug_information": { "unit": "100.000000", "type": "GR" }, "code_information": [ { "code": "51672135207", "type": "NDC" } ], "standard_charges": [ { "minimum": 261.77, "maximum": 873.19, "gross_charge": 928.93, "discounted_cash": 510.91, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 538.78, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 507.2, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 743.14, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 786.8, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 270.32, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 445.89, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 556.43, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 555.5, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 873.19, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 817.46, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 261.77, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 789.59, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 696.7, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 327.26, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 631.67, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 873.19, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 727.35, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 507.2, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 738.5, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 696.7, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 817.46, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 538.78, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 507.2, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DESOXIMETASONE 0.25 % EX OINT", "drug_information": { "unit": "60.000000", "type": "GR" }, "code_information": [ { "code": "51672520303", "type": "NDC" } ], "standard_charges": [ { "minimum": 226.09, "maximum": 754.16, "gross_charge": 802.3, "discounted_cash": 441.27, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 465.33, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 438.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 641.84, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 679.55, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 233.47, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 385.1, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 480.58, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 479.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 754.16, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 706.02, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 226.09, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 681.96, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 601.73, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 282.65, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 545.56, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 754.16, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 628.2, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 438.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 637.83, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 601.73, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 706.02, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 465.33, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 438.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Destroy cerv/thor facet jnt", "code_information": [ { "code": "64633", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1439.39, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1066.21, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 2926.4, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 5310.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1439.39, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 5310.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Destroy internal hemorrhoids", "code_information": [ { "code": "46930", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 869.1, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 643.78, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 4691.66, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 8513.1, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 869.1, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 8513.1, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Destroy lumb/sac facet jnt", "code_information": [ { "code": "64635", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1439.39, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1066.21, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 2941.28, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 5337.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1439.39, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 5337.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Destroy nerve face muscle", "code_information": [ { "code": "64612", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 217.58, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 161.17, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 4393.76, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 7972.56, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 217.58, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 7972.56, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Destroy nerve of eye muscle", "code_information": [ { "code": "67345", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 220.34, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 163.22, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 5475.66, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 9935.69, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 220.34, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 9935.69, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Destroy premal lesions 15/>", "code_information": [ { "code": "17004", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 294.49, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 1215.2, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 2205.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 294.49, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 2205.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Destroy vag lesions complex", "code_information": [ { "code": "57065", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2343.63, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1736.02, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 7850.17, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 14244.26, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2343.63, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 14244.26, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Destroy vag lesions simple", "code_information": [ { "code": "57061", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2343.63, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 8020.32, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 14553.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2343.63, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 14553.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Destroy vulva lesion/s compl", "code_information": [ { "code": "56515", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1348.33, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 998.76, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 10955.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 19878.05, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1348.33, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 19878.05, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Destroy vulva lesions sim", "code_information": [ { "code": "56501", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1348.33, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 4102.41, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 7443.9, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1348.33, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 7443.9, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Destruct b9 lesion 1-14", "code_information": [ { "code": "17110", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 146.46, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 352.16, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 639.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 146.46, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 639.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Destruct lesion 15 or more", "code_information": [ { "code": "17111", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 146.46, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 515.84, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 936.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 146.46, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 936.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Destruct premalg lesion", "code_information": [ { "code": "17000", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 146.46, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 947.36, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 1719.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 146.46, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 1719.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Destruction anal lesion(s)", "code_information": [ { "code": "46910", "type": "HCPCS" }, { "code": "46924", "type": "HCPCS" }, { "code": "46900", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2021.42, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 998.76, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1497.34, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 1086.24, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 1971.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 294.49, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1348.33, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2021.42, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 1971.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Destruction ciliary body", "code_information": [ { "code": "66720", "type": "HCPCS" }, { "code": "66740", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1719.62, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1273.8, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 7622.23, "methodology": "percent of 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"additional_generic_notes": "" } ] }, { "description": "Destruction penis lesion(s)", "code_information": [ { "code": "54065", "type": "HCPCS" }, { "code": "54050", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1348.33, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 998.76, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 674.56, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 1224.0, "methodology": "percent 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"methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DESVENLAFAXINE SUCCINATE ER 100 MG PO TB24", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68180059306", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", 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"standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DESVENLAFAXINE SUCCINATE ER 25 MG PO TB24", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00054060313", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", 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"percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", 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"additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DESVENLAFAXINE SUCCINATE ER 50 MG PO TB24", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687060721", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DEXAMETHASONE 0.4 MG OP INST", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "70382020410", "type": "NDC" } ], "standard_charges": [ { "minimum": 485.82, "maximum": 1620.56, "gross_charge": 1724.0, "discounted_cash": 948.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 999.92, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 941.3, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1379.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1460.23, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 501.68, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 827.52, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1032.68, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 1030.95, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1620.56, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1517.12, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 485.82, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1465.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1293.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 607.37, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1172.32, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1620.56, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1349.89, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 941.3, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1370.58, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1293.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1517.12, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 999.92, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 941.3, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DEXAMETHASONE 0.4 MG/ML SYRINGE (NICU)", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "63323016501", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DEXAMETHASONE 0.5 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00054817925", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DEXAMETHASONE 0.5 MG/5ML PO ELIX", "drug_information": { "unit": "237.000000", "type": "UN" }, "code_information": [ { "code": "60432046608", "type": "NDC" } ], "standard_charges": [ { "minimum": 32.45, "maximum": 108.24, "gross_charge": 115.15, "discounted_cash": 63.33, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 66.79, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 62.87, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 92.12, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 97.53, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.51, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.27, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 68.97, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 68.86, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 108.24, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 101.33, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.45, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 97.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.36, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.57, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 78.3, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 108.24, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 90.16, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 62.87, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 91.54, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.36, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 101.33, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 66.79, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 62.87, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DEXAMETHASONE 0.5 MG/5ML PO SOLN", "drug_information": { "unit": "240.000000", "type": "UN" }, "code_information": [ { "code": "00054317757", "type": "NDC" } ], "standard_charges": [ { "minimum": 19.77, "maximum": 65.94, "gross_charge": 70.15, "discounted_cash": 38.58, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.69, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.3, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 56.12, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.42, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.41, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.67, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.02, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.95, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.94, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.73, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.77, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.63, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.61, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.71, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.7, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.94, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.93, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.3, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.77, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.61, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.73, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.69, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.3, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DEXAMETHASONE 0.7 MG IZ IMPL", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00023334807", "type": "NDC" } ], "standard_charges": [ { "minimum": 1160.73, "maximum": 3871.86, "gross_charge": 4119.0, "discounted_cash": 2265.45, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2389.02, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2248.97, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3295.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3488.79, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1198.63, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1977.12, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2467.28, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2463.16, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3871.86, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3624.72, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1160.73, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3501.15, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3089.25, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1451.12, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2800.92, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3871.86, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3225.18, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2248.97, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3274.61, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3089.25, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3624.72, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2389.02, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2248.97, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DEXAMETHASONE 0.75 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00054818025", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DEXAMETHASONE 1 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "3535635930", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DEXAMETHASONE 1 MG/ML PO CONC", "drug_information": { "unit": "30.000000", "type": "UN" }, "code_information": [ { "code": "00054317644", "type": "NDC" } ], "standard_charges": [ { "minimum": 12.67, "maximum": 42.25, "gross_charge": 44.95, "discounted_cash": 24.72, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.07, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.54, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.96, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.07, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.08, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.58, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.93, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.88, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.25, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.56, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.67, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.21, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.71, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.84, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.57, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.25, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.54, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.74, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.71, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.56, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.07, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.54, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DEXAMETHASONE 1.5 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00054818125", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DEXAMETHASONE 2 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00054817625", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DEXAMETHASONE 4 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687071801", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DEXAMETHASONE 6 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687072901", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DEXAMETHASONE INTRAVITREAL INJ (0.4MG/0.05ML)", "drug_information": { "unit": "1.250000", "type": "UN" }, "code_information": [ { "code": "C6332350615", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DEXAMETHASONE INTRAVITREAL INJ (0.4MG/0.1ML)", "drug_information": { "unit": "2.500000", "type": "UN" }, "code_information": [ { "code": "C6332350611", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DEXAMETHASONE SOD PHOSPHATE PF 10 MG/ML IJ SOLN", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "70069002125", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DEXAMETHASONE SODIUM PHOS 10 MG/ML IJ SOLN 1 ML VIAL (BULK CHARGE)", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00641036725", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DEXAMETHASONE SODIUM PHOS 4 MG/ML IJ SOLN 1 ML VIAL (BULK CHARGE)", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "63323016501_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DEXAMETHASONE SODIUM PHOS 4 MG/ML IJ SOLN 5 ML BOTTLE (BULK CHARGE)", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "67457042254", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed 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"standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DEXAMETHASONE SODIUM PHOSPHATE 0.1 % INTRATRACHEA SOLN", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "24208072002", "type": "NDC" } ], "standard_charges": [ { "minimum": 29.56, "maximum": 98.61, "gross_charge": 104.9, "discounted_cash": 57.7, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.84, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 57.28, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 83.92, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.85, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.53, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.35, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 62.84, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 62.73, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 98.61, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 92.31, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.56, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 89.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 78.68, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.96, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 71.33, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 98.61, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.14, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 57.28, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 83.4, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 78.68, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 92.31, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.84, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 57.28, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DEXAMETHASONE SODIUM PHOSPHATE 0.1 % OP SOLN", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "24208072002_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 29.56, "maximum": 98.61, "gross_charge": 104.9, "discounted_cash": 57.7, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.84, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 57.28, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 83.92, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.85, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.53, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.35, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 62.84, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 62.73, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 98.61, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 92.31, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.56, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 89.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 78.68, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.96, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 71.33, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 98.61, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.14, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 57.28, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 83.4, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 78.68, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 92.31, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.84, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 57.28, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DEXAMETHASONE SODIUM PHOSPHATE 0.1 % OP SOLN (OTIC USE)", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "24208072002_3", "type": "NDC" } ], "standard_charges": [ { "minimum": 29.56, "maximum": 98.61, "gross_charge": 104.9, "discounted_cash": 57.7, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.84, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 57.28, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 83.92, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.85, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.53, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.35, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 62.84, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 62.73, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 98.61, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 92.31, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.56, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 89.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 78.68, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.96, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 71.33, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 98.61, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.14, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 57.28, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 83.4, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 78.68, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 92.31, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.84, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 57.28, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML IJ SOLN", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00641036725_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DEXAMETHASONE SODIUM PHOSPHATE 20 MG/5ML IJ SOLN", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "67457042254_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML IJ SOLN", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "67457042312", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML IJ SOLN (IV FOR PO)", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "67457042312_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML IJ SOLN (NICU)", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "67457042312_3", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML IJ SOLN FOR INHALATION", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "67457042312_4", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DEXLANSOPRAZOLE 60 MG PO CPDR", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "64764017530", "type": "NDC" } ], "standard_charges": [ { "minimum": 6.56, "maximum": 21.88, "gross_charge": 23.28, "discounted_cash": 12.8, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.5, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.71, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.62, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.72, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.77, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.17, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.94, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.88, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.49, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.56, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.79, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.46, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.2, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.83, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.88, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.23, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.71, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.51, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.46, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.49, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.5, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.71, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DEXMEDETOMIDINE 400 MCG/100ML DRIP RTU (TITRATABLE RATE)", "drug_information": { "unit": "100.000000", "type": "UN" }, "code_information": [ { "code": "00143952510", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 1158.0, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 95.48, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DEXMEDETOMIDINE HCL 200 MCG/2ML IV SOLN", "drug_information": { "unit": "2.000000", "type": "UN" }, "code_information": [ { "code": "71288050503", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 1158.0, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.72, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DEXMEDETOMIDINE HCL IN NACL 400 MCG/100ML RTU (PEDS)", "drug_information": { "unit": "100.000000", "type": "UN" }, "code_information": [ { "code": "00143952510_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 1158.0, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 95.48, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DEXMEDETOMIDINE HCL IN NACL 80 MCG/20ML IV SOLN", "drug_information": { "unit": "20.000000", "type": "UN" }, "code_information": [ { "code": "00781349395", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 1158.0, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 95.48, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DEXMETHYLPHENIDATE HCL 2.5 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "R0093527501", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.25, "maximum": 7.52, "gross_charge": 8.0, "discounted_cash": 4.4, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.4, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.78, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.33, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.84, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": 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"plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.8, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.82, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.44, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.26, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.36, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DEXMETHYLPHENIDATE HCL 5 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "R1070210701", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.25, "maximum": 7.52, "gross_charge": 8.0, "discounted_cash": 4.4, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", 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"plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.84, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.79, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.25, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.8, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.82, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.44, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.26, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.36, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DEXMETHYLPHENIDATE HCL ER 10 MG PO CP24", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "1671456301", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.25, "maximum": 7.52, "gross_charge": 8.0, "discounted_cash": 4.4, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.4, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.78, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.33, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.84, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.79, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.25, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.8, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.82, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.44, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.26, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.36, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DEXMETHYLPHENIDATE HCL ER 20 MG PO CP24", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00078043205", "type": "NDC" } ], "standard_charges": [ { "minimum": 3.27, "maximum": 10.92, "gross_charge": 11.62, "discounted_cash": 6.39, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.74, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.34, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.3, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.84, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.38, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.58, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.95, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.92, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.23, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.72, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.9, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.92, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.1, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.34, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.24, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.72, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.23, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.74, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.34, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DEXMETHYLPHENIDATE HCL ER 5 MG PO CP24", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "R0527810637", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.25, "maximum": 7.52, "gross_charge": 8.0, "discounted_cash": 4.4, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.4, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.78, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.33, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.84, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.79, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.25, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.8, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.82, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.44, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.26, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.36, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DEXRAZOXANE 10 MG/ML SYRINGE", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "72611071601_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 47.77, "maximum": 491.76, "gross_charge": 523.15, "discounted_cash": 287.73, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 303.43, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.77, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 418.52, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 443.11, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 152.24, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 251.11, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 313.37, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 312.84, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 491.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 460.37, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 147.42, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 444.68, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 392.36, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 184.31, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 355.74, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 491.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 409.63, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 64.49, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 415.9, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 392.36, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 460.37, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 303.43, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.77, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "DEXRAZOXANE 10 MG/ML SYRINGE|DISCARDED DRUG NOT ADMINISTERED", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "72611071601", "type": "NDC" } ], "standard_charges": [ { "minimum": 47.77, "maximum": 425.96, "gross_charge": 453.15, "discounted_cash": 249.23, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 262.83, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.77, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 362.52, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 383.82, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 131.87, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 217.51, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 271.44, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 270.98, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 425.96, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 398.77, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 127.7, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 385.18, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 339.86, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 159.64, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 308.14, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 425.96, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 354.82, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 64.49, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 360.25, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 339.86, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 398.77, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 262.83, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.77, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "DEXRAZOXANE HCL 250 MG IV SOLR", "drug_information": { "unit": "25.000000", "type": "UN" }, "code_information": [ { "code": "00143924701", "type": "NDC" } ], "standard_charges": [ { "minimum": 47.77, "maximum": 438.03, "gross_charge": 465.99, "discounted_cash": 256.29, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 270.27, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.77, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 372.79, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 394.69, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 135.6, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 223.68, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 279.13, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 278.66, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 438.03, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 410.07, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 131.32, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 396.09, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 349.49, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 164.17, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 316.87, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 438.03, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 364.87, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 64.49, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 370.46, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 349.49, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 410.07, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 270.27, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.77, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "DEXRAZOXANE HCL 500 MG IV SOLR", "drug_information": { "unit": "50.000000", "type": "UN" }, "code_information": [ { "code": "72266010101", "type": "NDC" } ], "standard_charges": [ { "minimum": 47.77, "maximum": 404.51, "gross_charge": 430.33, "discounted_cash": 236.68, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 249.59, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.77, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 344.26, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 364.49, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 125.23, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 206.56, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 257.77, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 257.34, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 404.51, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 378.69, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 121.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 365.78, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 322.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 151.61, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 292.62, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 404.51, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 336.95, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 64.49, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 342.11, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 322.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 378.69, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 249.59, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.77, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "DEXTRAN 40 IN D5W 10 % IV SOLN", "drug_information": { "unit": "500.000000", "type": "UN" }, "code_information": [ { "code": "00409741803", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DEXTRAN 40 IN SALINE 10-0.9 % IV SOLN", "drug_information": { "unit": "500.000000", "type": "UN" }, "code_information": [ { "code": "00409741903", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DEXTROAMPHETAMINE SULFATE 10 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00555095302", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.25, "maximum": 7.52, "gross_charge": 8.0, "discounted_cash": 4.4, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.4, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.78, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.33, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.84, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.79, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.25, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.8, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.82, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.44, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.26, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.36, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DEXTROAMPHETAMINE SULFATE 5 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "R0555095202", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.25, "maximum": 7.52, "gross_charge": 8.0, "discounted_cash": 4.4, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.4, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.78, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.33, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.84, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.79, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.25, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.8, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.82, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.44, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.26, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.36, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DEXTROAMPHETAMINE SULFATE ER 10 MG PO CP24", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "R0406896101", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.25, "maximum": 7.52, "gross_charge": 8.0, "discounted_cash": 4.4, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.4, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.78, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.33, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.84, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.79, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.25, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.8, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.82, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.44, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.26, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.36, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DEXTROAMPHETAMINE SULFATE ER 15 MG PO CP24", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00406896201", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.25, "maximum": 7.52, "gross_charge": 8.0, "discounted_cash": 4.4, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.4, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.78, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.33, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.84, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.79, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.25, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.8, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.82, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.44, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.26, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.36, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DEXTROAMPHETAMINE SULFATE ER 5 MG PO CP24", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "R4596330309", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.25, "maximum": 7.52, "gross_charge": 8.0, "discounted_cash": 4.4, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.4, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.78, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.33, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.84, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.79, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.25, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.8, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.82, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.44, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.26, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.36, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DEXTROMETHORPHAN HBR 7.5 MG/5ML PO SYRP", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "00031869412", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DEXTROMETHORPHAN POLISTIREX ER 30 MG/5ML PO SUER", "drug_information": { "unit": "2.500000", "type": "UN" }, "code_information": [ { "code": "45802043321", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DEXTROSE 10 % IV BOLUS", "drug_information": { "unit": "1000.000000", "type": "UN" }, "code_information": [ { "code": "00338002304", "type": "NDC" } ], "standard_charges": [ { "minimum": 19.73, "maximum": 1158.0, "gross_charge": 70.0, "discounted_cash": 38.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.76, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.37, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.93, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.86, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.73, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.66, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.6, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.81, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.65, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DEXTROSE 10 % IV BOLUS (PEDS DKA)", "drug_information": { "unit": "1000.000000", "type": "UN" }, "code_information": [ { "code": "00338002304_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 19.73, "maximum": 1158.0, "gross_charge": 70.0, "discounted_cash": 38.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.76, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.37, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.93, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.86, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.73, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.66, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.6, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.81, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.65, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DEXTROSE 10 % IV MINI-BOLUS (NICU)", "drug_information": { "unit": "1000.000000", "type": "UN" }, "code_information": [ { "code": "00338002304_3", "type": "NDC" } ], "standard_charges": [ { "minimum": 19.73, "maximum": 1158.0, "gross_charge": 70.0, "discounted_cash": 38.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.76, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.37, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.93, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.86, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.73, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.66, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.6, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.81, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.65, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DEXTROSE 10 % IV SOLN", "drug_information": { "unit": "1000.000000", "type": "UN" }, "code_information": [ { "code": "00338002304_4", "type": "NDC" } ], "standard_charges": [ { "minimum": 19.73, "maximum": 1158.0, "gross_charge": 70.0, "discounted_cash": 38.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.76, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.37, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.93, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.86, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.73, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.66, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.6, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.81, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.65, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DEXTROSE 10 % IV SOLN (HIET PROTOCOL)", "drug_information": { "unit": "1000.000000", "type": "UN" }, "code_information": [ { "code": "00338002304_5", "type": "NDC" } ], "standard_charges": [ { "minimum": 19.73, "maximum": 1158.0, "gross_charge": 70.0, "discounted_cash": 38.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.76, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.37, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.93, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.86, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.73, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.66, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.6, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.81, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.65, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DEXTROSE 10 % IV SOLN (PEDS DKA)", "drug_information": { "unit": "1000.000000", "type": "UN" }, "code_information": [ { "code": "00338002304_6", "type": "NDC" } ], "standard_charges": [ { "minimum": 19.73, "maximum": 1158.0, "gross_charge": 70.0, "discounted_cash": 38.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.76, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.37, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.93, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.86, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.73, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.66, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.6, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.81, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.65, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DEXTROSE 10 % IV SOLN 500 ML (BULK CHARGE)", "drug_information": { "unit": "500.000000", "type": "UN" }, "code_information": [ { "code": "00338002303", "type": "NDC" } ], "standard_charges": [ { "minimum": 19.73, "maximum": 1158.0, "gross_charge": 70.0, "discounted_cash": 38.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.76, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.37, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.93, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.86, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.73, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.66, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.6, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.81, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.65, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DEXTROSE 10 %/0.45 % NACL", "drug_information": { "unit": "1000.000000", "type": "UN" }, "code_information": [ { "code": "00264762200", "type": "NDC" } ], "standard_charges": [ { "minimum": 19.73, "maximum": 1158.0, "gross_charge": 70.0, "discounted_cash": 38.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.76, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.37, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.93, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.86, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.73, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.66, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.6, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.81, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.65, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DEXTROSE 12.5% IV SOLN (CUSTOM)", "drug_information": { "unit": "1000.000000", "type": "UN" }, "code_information": [ { "code": "08252000128", "type": "NDC" } ], "standard_charges": [ { "minimum": 19.73, "maximum": 1158.0, "gross_charge": 70.0, "discounted_cash": 38.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.76, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.37, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.93, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.86, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.73, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.66, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.6, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.81, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.65, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DEXTROSE 20 % IV SOLN", "drug_information": { "unit": "500.000000", "type": "UN" }, "code_information": [ { "code": "00990793519", "type": "NDC" } ], "standard_charges": [ { "minimum": 19.73, "maximum": 1158.0, "gross_charge": 70.0, "discounted_cash": 38.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.76, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.37, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.93, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.86, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.73, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.66, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.6, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.81, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.65, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DEXTROSE 20 % IV SOLN (HIET PROTOCOL)", "drug_information": { "unit": "500.000000", "type": "UN" }, "code_information": [ { "code": "00990793519_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 19.73, "maximum": 1158.0, "gross_charge": 70.0, "discounted_cash": 38.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.76, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.37, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.93, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.86, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.73, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.66, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.6, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.81, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.65, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DEXTROSE 20% ORAL SOLUTION", "drug_information": { "unit": "480.000000", "type": "UN" }, "code_information": [ { "code": "08252000286", "type": "NDC" } ], "standard_charges": [ { "minimum": 4.4, "maximum": 14.66, "gross_charge": 15.6, "discounted_cash": 8.58, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.05, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.52, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.48, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.21, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.54, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.49, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.34, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.33, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.66, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.73, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.4, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.26, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.7, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.5, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.61, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.66, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.21, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.52, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.4, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.7, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.73, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.05, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.52, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DEXTROSE 5 % AND 0.45 % NACL IV BOLUS", "drug_information": { "unit": "250.000000", "type": "UN" }, "code_information": [ { "code": "00338008504_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 19.73, "maximum": 1158.0, "gross_charge": 70.0, "discounted_cash": 38.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.76, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.37, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.93, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.86, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.73, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.66, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.6, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.81, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.65, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DEXTROSE 5 % IV BOLUS", "drug_information": { "unit": "250.000000", "type": "UN" }, "code_information": [ { "code": "00338001704", "type": "NDC" } ], "standard_charges": [ { "minimum": 19.73, "maximum": 1158.0, "gross_charge": 70.0, "discounted_cash": 38.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.76, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.37, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.93, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.86, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.73, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.66, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.6, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.81, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.65, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DEXTROSE 5 % IV SOLN", "drug_information": { "unit": "1000.000000", "type": "UN" }, "code_information": [ { "code": "00338001704_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 19.73, "maximum": 1158.0, "gross_charge": 70.0, "discounted_cash": 38.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.76, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.37, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.93, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.86, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.73, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.66, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.6, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.81, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.65, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DEXTROSE 5 % IV SOLN 100 ML (BULK CHARGE)", "drug_information": { "unit": "100.000000", "type": "UN" }, "code_information": [ { "code": "00338001748", "type": "NDC" } ], "standard_charges": [ { "minimum": 19.73, "maximum": 1158.0, "gross_charge": 70.0, "discounted_cash": 38.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.76, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.37, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.93, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.86, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.73, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.66, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.6, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.81, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.65, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DEXTROSE 5 % IV SOLN 1000ML (BULK CHARGE)", "drug_information": { "unit": "1000.000000", "type": "UN" }, "code_information": [ { "code": "00338001704_3", "type": "NDC" } ], "standard_charges": [ { "minimum": 19.73, "maximum": 1158.0, "gross_charge": 70.0, "discounted_cash": 38.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.76, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.37, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.93, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.86, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.73, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.66, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.6, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.81, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.65, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DEXTROSE 5 % IV SOLN 250 ML (BULK CHARGE)", "drug_information": { "unit": "250.000000", "type": "UN" }, "code_information": [ { "code": "00338001702", "type": "NDC" } ], "standard_charges": [ { "minimum": 19.73, "maximum": 1158.0, "gross_charge": 70.0, "discounted_cash": 38.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.76, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.37, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.93, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.86, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.73, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.66, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.6, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.81, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.65, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DEXTROSE 5 % IV SOLN 500ML (BULK CHARGE)", "drug_information": { "unit": "500.000000", "type": "UN" }, "code_information": [ { "code": "00338001703", "type": "NDC" } ], "standard_charges": [ { "minimum": 19.73, "maximum": 1158.0, "gross_charge": 70.0, "discounted_cash": 38.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.76, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.37, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.93, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.86, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.73, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.66, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.6, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.81, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.65, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DEXTROSE 5 % IV SOLN 50ML (BULK CHARGE)", "drug_information": { "unit": "50.000000", "type": "UN" }, "code_information": [ { "code": "00338001731", "type": "NDC" } ], "standard_charges": [ { "minimum": 19.73, "maximum": 1158.0, "gross_charge": 70.0, "discounted_cash": 38.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.76, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.37, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.93, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.86, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.73, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.66, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.6, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.81, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.65, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DEXTROSE 5 % IV SOLN DEHP FREE", "drug_information": { "unit": "500.000000", "type": "UN" }, "code_information": [ { "code": "00264751010", "type": "NDC" } ], "standard_charges": [ { "minimum": 19.73, "maximum": 1158.0, "gross_charge": 70.0, "discounted_cash": 38.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.76, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.37, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.93, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.86, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.73, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.66, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.6, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.81, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.65, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DEXTROSE 5 % POSTDILUTION SOLUTION", "drug_information": { "unit": "1000.000000", "type": "UN" }, "code_information": [ { "code": "00338001704_4", "type": "NDC" } ], "standard_charges": [ { "minimum": 19.73, "maximum": 1158.0, "gross_charge": 70.0, "discounted_cash": 38.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.76, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.37, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.93, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.86, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.73, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.66, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.6, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.81, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.65, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DEXTROSE 5 % PREDILUTION SOLUTION", "drug_information": { "unit": "1000.000000", "type": "UN" }, "code_information": [ { "code": "00338001704_5", "type": "NDC" } ], "standard_charges": [ { "minimum": 19.73, "maximum": 1158.0, "gross_charge": 70.0, "discounted_cash": 38.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.76, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.37, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.93, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.86, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.73, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.66, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.6, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.81, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.65, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DEXTROSE 5 %/0.2 % NACL", "drug_information": { "unit": "1000.000000", "type": "UN" }, "code_information": [ { "code": "00338007704", "type": "NDC" } ], "standard_charges": [ { "minimum": 19.73, "maximum": 1158.0, "gross_charge": 70.0, "discounted_cash": 38.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.76, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.37, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.93, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.86, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.73, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.66, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.6, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.81, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.65, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DEXTROSE 5 %/0.2 % NACL/20 MEQ KCL", "drug_information": { "unit": "1000.000000", "type": "UN" }, "code_information": [ { "code": "00264764500", "type": "NDC" } ], "standard_charges": [ { "minimum": 28.18, "maximum": 1158.0, "gross_charge": 100.0, "discounted_cash": 55.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 58.0, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.6, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.8, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.1, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 48.0, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.9, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.8, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 94.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.18, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 85.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.23, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 68.0, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 94.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 78.3, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.6, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 79.5, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 58.0, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.6, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DEXTROSE 5 %/0.45 % NACL", "drug_information": { "unit": "1000.000000", "type": "UN" }, "code_information": [ { "code": "00338008504_3", "type": "NDC" } ], "standard_charges": [ { "minimum": 19.73, "maximum": 1158.0, "gross_charge": 70.0, "discounted_cash": 38.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.76, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.37, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.93, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.86, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.73, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.66, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.6, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.81, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.65, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DEXTROSE 5 %/0.45 % NACL 500ML (BULK CHARGE)", "drug_information": { "unit": "500.000000", "type": "UN" }, "code_information": [ { "code": "00338008503", "type": "NDC" } ], "standard_charges": [ { "minimum": 19.73, "maximum": 1158.0, "gross_charge": 70.0, "discounted_cash": 38.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.76, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.37, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.93, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.86, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.73, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.66, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.6, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.81, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.65, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DEXTROSE 5 %/0.45 % NACL/10 MEQ KCL", "drug_information": { "unit": "1000.000000", "type": "UN" }, "code_information": [ { "code": "00338066904", "type": "NDC" } ], "standard_charges": [ { "minimum": 28.18, "maximum": 94.0, "gross_charge": 100.0, "discounted_cash": 55.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 58.0, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.6, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 80.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 84.7, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.1, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 48.0, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.9, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.8, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 94.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.18, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 85.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.23, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 68.0, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 94.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 78.3, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.6, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 79.5, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 58.0, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.6, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DEXTROSE 5 %/0.45 % NACL/20 MEQ KCL", "drug_information": { "unit": "1000.000000", "type": "UN" }, "code_information": [ { "code": "00338067104", "type": "NDC" } ], "standard_charges": [ { "minimum": 28.18, "maximum": 94.0, "gross_charge": 100.0, "discounted_cash": 55.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 58.0, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.6, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 80.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 84.7, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.1, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 48.0, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.9, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.8, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 94.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.18, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 85.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.23, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 68.0, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 94.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 78.3, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.6, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 79.5, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 58.0, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.6, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DEXTROSE 5 %/0.45 % NACL/30 MEQ KCL", "drug_information": { "unit": "1000.000000", "type": "UN" }, "code_information": [ { "code": "00338067304", "type": "NDC" } ], "standard_charges": [ { "minimum": 28.18, "maximum": 1158.0, "gross_charge": 100.0, "discounted_cash": 55.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 58.0, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.6, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.8, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.1, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 48.0, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.9, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.8, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 94.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.18, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 85.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.23, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 68.0, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 94.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 78.3, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.6, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 79.5, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 58.0, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.6, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DEXTROSE 5 %/0.45 % NACL/40 MEQ KCL", "drug_information": { "unit": "1000.000000", "type": "UN" }, "code_information": [ { "code": "00338067504", "type": "NDC" } ], "standard_charges": [ { "minimum": 28.18, "maximum": 1158.0, "gross_charge": 100.0, "discounted_cash": 55.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 58.0, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.6, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.8, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.1, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 48.0, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.9, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.8, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 94.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.18, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 85.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.23, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 68.0, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 94.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 78.3, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.6, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 79.5, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 58.0, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.6, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DEXTROSE 5 %/0.45% NACL 1000ML (BULK CHARGE)", "drug_information": { "unit": "1000.000000", "type": "UN" }, "code_information": [ { "code": "00338008504_4", "type": "NDC" } ], "standard_charges": [ { "minimum": 19.73, "maximum": 1158.0, "gross_charge": 70.0, "discounted_cash": 38.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.76, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.37, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.93, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.86, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.73, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.66, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.6, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.81, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.65, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DEXTROSE 5 %/0.9 % NACL/20 MEQ KCL", "drug_information": { "unit": "1000.000000", "type": "UN" }, "code_information": [ { "code": "00338080304", "type": "NDC" } ], "standard_charges": [ { "minimum": 28.18, "maximum": 94.0, "gross_charge": 100.0, "discounted_cash": 55.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 58.0, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.6, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 80.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 84.7, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.1, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 48.0, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.9, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.8, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 94.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.18, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 85.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.23, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 68.0, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 94.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 78.3, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.6, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 79.5, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 58.0, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.6, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DEXTROSE 5 %/LACTATED RINGERS", "drug_information": { "unit": "1000.000000", "type": "UN" }, "code_information": [ { "code": "00338012504", "type": "NDC" } ], "standard_charges": [ { "minimum": 19.73, "maximum": 1158.0, "gross_charge": 70.0, "discounted_cash": 38.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.76, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.37, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.93, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.86, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.73, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.66, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.6, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.81, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.65, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DEXTROSE 5% BOLUS (IV FOR PO)", "drug_information": { "unit": "250.000000", "type": "UN" }, "code_information": [ { "code": "00338001704_6", "type": "NDC" } ], "standard_charges": [ { "minimum": 19.73, "maximum": 65.8, "gross_charge": 70.0, "discounted_cash": 38.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 56.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.29, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.37, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.93, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.86, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.73, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.66, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.6, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.81, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.65, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DEXTROSE 5% IV SOLN (100 ML)", "drug_information": { "unit": "100.000000", "type": "UN" }, "code_information": [ { "code": "00338001748_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 19.73, "maximum": 1158.0, "gross_charge": 70.0, "discounted_cash": 38.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.76, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.37, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.93, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.86, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.73, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.66, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.6, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.81, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.65, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DEXTROSE 5% IV SOLN (250 ML)", "drug_information": { "unit": "250.000000", "type": "UN" }, "code_information": [ { "code": "00338001702_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 19.73, "maximum": 1158.0, "gross_charge": 70.0, "discounted_cash": 38.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.76, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.37, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.93, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.86, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.73, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.66, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.6, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.81, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.65, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DEXTROSE 5% IV SOLN (500 ML)", "drug_information": { "unit": "500.000000", "type": "UN" }, "code_information": [ { "code": "00338001703_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 19.73, "maximum": 1158.0, "gross_charge": 70.0, "discounted_cash": 38.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.76, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.37, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.93, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.86, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.73, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.66, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.6, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.81, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.65, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DEXTROSE 5%/0.9% NACL 1000ML (BULK CHARGE)", "drug_information": { "unit": "500.000000", "type": "UN" }, "code_information": [ { "code": "00338008904", "type": "NDC" } ], "standard_charges": [ { "minimum": 19.73, "maximum": 1158.0, "gross_charge": 70.0, "discounted_cash": 38.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.76, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.37, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.93, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.86, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.73, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.66, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.6, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.81, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.65, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DEXTROSE 5%/0.9% NACL 500ML (BULK CHARGE)", "drug_information": { "unit": "500.000000", "type": "UN" }, "code_information": [ { "code": "00338008903", "type": "NDC" } ], "standard_charges": [ { "minimum": 19.73, "maximum": 1158.0, "gross_charge": 70.0, "discounted_cash": 38.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.76, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.37, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.93, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.86, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.73, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.66, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.6, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.81, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.65, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DEXTROSE 50 % IV SOLN", "drug_information": { "unit": "50.000000", "type": "UN" }, "code_information": [ { "code": "00409664802", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 1158.0, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.72, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DEXTROSE 50 % IV SOLN 50 ML SYRINGE (BULK CHARGE)", "drug_information": { "unit": "50.000000", "type": "UN" }, "code_information": [ { "code": "00409490234", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 1158.0, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.72, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DEXTROSE 50 % IV SOLN 50 ML VIAL (BULK CHARGE)", "drug_information": { "unit": "50.000000", "type": "UN" }, "code_information": [ { "code": "00409664802_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 1158.0, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.72, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DEXTROSE 50 % IV SOLN FOR INITIATION (HIET PROTOCOL)", "drug_information": { "unit": "50.000000", "type": "UN" }, "code_information": [ { "code": "00409664802_3", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 1158.0, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.72, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DEXTROSE 50 % IV SOLN FOR MAINTENANCE (HIET PROTOCOL)", "drug_information": { "unit": "50.000000", "type": "UN" }, "code_information": [ { "code": "00409664802_4", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 1158.0, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.72, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DEXTROSE 70 % IV SOLN", "drug_information": { "unit": "2000.000000", "type": "UN" }, "code_information": [ { "code": "00338071906", "type": "NDC" } ], "standard_charges": [ { "minimum": 19.73, "maximum": 1158.0, "gross_charge": 70.0, "discounted_cash": 38.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.76, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.37, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.93, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.86, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.73, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.66, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.6, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.81, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.65, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DEXTROSE-NACL 10-0.45 % IV SOLN", "drug_information": { "unit": "1000.000000", "type": "UN" }, "code_information": [ { "code": "00264762200_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 19.73, "maximum": 1158.0, "gross_charge": 70.0, "discounted_cash": 38.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.76, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.37, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.93, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.86, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.73, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.66, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.6, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.81, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.65, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DEXTROSE-NACL 10-0.45 % IV SOLN (PEDS DKA)", "drug_information": { "unit": "1000.000000", "type": "UN" }, "code_information": [ { "code": "00264762200_3", "type": "NDC" } ], "standard_charges": [ { "minimum": 19.73, "maximum": 1158.0, "gross_charge": 70.0, "discounted_cash": 38.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.76, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.37, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.93, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.86, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.73, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.66, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.6, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.81, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.65, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DEXTROSE-NACL 5-0.9 % IV SOLN", "drug_information": { "unit": "1000.000000", "type": "UN" }, "code_information": [ { "code": "00338008904_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 19.73, "maximum": 1158.0, "gross_charge": 70.0, "discounted_cash": 38.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.76, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.37, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.93, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.86, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.73, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.66, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.6, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.81, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.65, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DEXTROSE-SODIUM CHLORIDE 2.5-0.45 % IV SOLN", "drug_information": { "unit": "1000.000000", "type": "UN" }, "code_information": [ { "code": "00338007304", "type": "NDC" } ], "standard_charges": [ { "minimum": 19.73, "maximum": 1158.0, "gross_charge": 70.0, "discounted_cash": 38.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.76, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.37, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.93, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.86, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.73, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.66, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.6, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.81, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.65, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DEXTROSE-SODIUM CHLORIDE 5-0.45 % IV SOLN", "drug_information": { "unit": "1000.000000", "type": "UN" }, "code_information": [ { "code": "00338008504", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 1158.0, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.72, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Diag bronchoscope/catheter", "code_information": [ { "code": "31643", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1271.11, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 941.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 26127.79, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 47409.3, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1271.11, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 47409.3, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Diag laparo separate proc", "code_information": [ { "code": "49320", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4300.51, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3185.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 12345.74, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 22401.54, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4300.51, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 22401.54, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Diagnostic anoscopy & biopsy", "code_information": [ { "code": "46607", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 869.1, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 643.78, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 6365.66, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 11550.6, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 869.1, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 11550.6, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Diagnostic anoscopy spx", "code_information": [ { "code": "46600", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 95.01, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 545.6, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 990.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 95.01, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 990.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Diagnostic colonoscopy", "code_information": [ { "code": "45378", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 672.02, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 497.79, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 2713.11, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 4923.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 672.02, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 4923.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Diagnostic laryngoscopy", "code_information": [ { "code": "31575", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 143.1, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 509.83, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 925.09, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 143.1, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 925.09, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Diagnostic sigmoidoscopy", "code_information": [ { "code": "45330", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 672.02, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 497.79, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 2504.8, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 4545.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 672.02, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 4545.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DIATRIZOATE MEGLUMINE & SODIUM 66-10 % PO SOLN (NON-DIAGNOSTIC)", "drug_information": { "unit": "120.000000", "type": "UN" }, "code_information": [ { "code": "00270044540", "type": "NDC" } ], "standard_charges": [ { "minimum": 13.27, "maximum": 44.26, "gross_charge": 47.08, "discounted_cash": 25.89, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.31, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.71, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.66, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.7, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.2, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.15, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 44.26, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.43, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.02, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.31, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.59, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 44.26, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.86, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.71, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.43, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.31, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.43, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.31, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.71, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DIAZEPAM (15 MG DOSE) 2 X 7.5 MG/0.1ML NA LQPK", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "72252051504", "type": "NDC" } ], "standard_charges": [ { "minimum": 355.8, "maximum": 1186.84, "gross_charge": 1262.6, "discounted_cash": 694.43, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 732.31, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 689.38, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1010.08, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1069.42, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 367.42, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 606.05, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 756.3, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 755.03, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1186.84, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1111.09, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 355.8, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1073.21, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 946.95, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 444.81, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 858.57, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1186.84, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 988.62, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 689.38, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1003.77, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 946.95, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1111.09, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 732.31, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 689.38, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DIAZEPAM (20 MG DOSE) 2 X 10 MG/0.1ML NA LQPK", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "72252052004", "type": "NDC" } ], "standard_charges": [ { "minimum": 355.8, "maximum": 1186.84, "gross_charge": 1262.6, "discounted_cash": 694.43, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 732.31, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 689.38, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1010.08, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1069.42, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 367.42, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 606.05, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 756.3, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 755.03, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1186.84, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1111.09, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 355.8, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1073.21, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 946.95, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 444.81, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 858.57, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1186.84, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 988.62, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 689.38, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1003.77, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 946.95, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1111.09, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 732.31, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 689.38, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DIAZEPAM 1 MG/ML PO SOLN", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "68094075062", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.25, "maximum": 7.52, "gross_charge": 8.0, "discounted_cash": 4.4, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.4, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.78, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.33, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.84, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.79, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.25, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.8, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.82, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.44, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.26, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.36, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DIAZEPAM 10 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "51079028620", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.25, "maximum": 7.52, "gross_charge": 8.0, "discounted_cash": 4.4, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.4, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.78, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.33, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.84, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.79, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.25, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.8, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.82, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.44, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.26, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.36, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DIAZEPAM 10 MG RE GEL", "drug_information": { "unit": "2.000000", "type": "UN" }, "code_information": [ { "code": "68682065220", "type": "NDC" } ], "standard_charges": [ { "minimum": 232.94, "maximum": 777.03, "gross_charge": 826.63, "discounted_cash": 454.65, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 479.45, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 451.34, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 661.3, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 700.16, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 240.55, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 396.78, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 495.15, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 494.32, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 777.03, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 727.43, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 232.94, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 702.64, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 619.97, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 291.22, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 562.11, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 777.03, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 647.25, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 451.34, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 657.17, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 619.97, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 727.43, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 479.45, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 451.34, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DIAZEPAM 10 MG/0.1ML NA LIQD", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "72252051002", "type": "NDC" } ], "standard_charges": [ { "minimum": 355.8, "maximum": 1186.84, "gross_charge": 1262.6, "discounted_cash": 694.43, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 732.31, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 689.38, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1010.08, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1069.42, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 367.42, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 606.05, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 756.3, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 755.03, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1186.84, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1111.09, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 355.8, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1073.21, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 946.95, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 444.81, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 858.57, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1186.84, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 988.62, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 689.38, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1003.77, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 946.95, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1111.09, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 732.31, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 689.38, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DIAZEPAM 10 MG/2 ML INJ (BULK CHARGE)", "drug_information": { "unit": "2.000000", "type": "UN" }, "code_information": [ { "code": "00409127332", "type": "NDC" } ], "standard_charges": [ { "minimum": 15.19, "maximum": 50.66, "gross_charge": 53.89, "discounted_cash": 29.64, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.26, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.42, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.11, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.64, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.68, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.87, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.28, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.23, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.66, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.42, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.19, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.81, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.42, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.99, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.65, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.66, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.2, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.42, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.84, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.42, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.42, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.26, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.42, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DIAZEPAM 2 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "51079028420", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.25, "maximum": 7.52, "gross_charge": 8.0, "discounted_cash": 4.4, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.4, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.78, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.33, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.84, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.79, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.25, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.8, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.82, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.44, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.26, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.36, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DIAZEPAM 2.5 MG RE GEL", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "6868265020", "type": "NDC" } ], "standard_charges": [ { "minimum": 102.29, "maximum": 341.21, "gross_charge": 362.99, "discounted_cash": 199.64, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 210.53, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 198.19, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 290.39, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 307.45, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 105.63, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 174.24, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 217.43, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 217.07, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 341.21, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 319.43, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 102.29, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 308.54, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 272.24, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 127.88, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 246.83, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 341.21, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 284.22, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 198.19, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 288.58, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 272.24, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 319.43, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 210.53, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 198.19, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DIAZEPAM 20 MG RE GEL", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68682065520", "type": "NDC" } ], "standard_charges": [ { "minimum": 103.92, "maximum": 346.65, "gross_charge": 368.78, "discounted_cash": 202.83, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 213.89, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 201.35, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 295.02, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 312.36, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 107.31, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 177.01, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 220.9, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 220.53, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 346.65, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 324.53, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.92, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 313.46, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 276.59, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 129.92, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 250.77, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 346.65, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 288.75, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 201.35, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 293.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 276.59, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 324.53, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 213.89, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 201.35, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DIAZEPAM 5 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "51079028520", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.25, "maximum": 7.52, "gross_charge": 8.0, "discounted_cash": 4.4, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.4, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.78, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.33, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.84, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.79, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.25, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.8, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.82, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.44, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.26, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.36, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DIAZEPAM 5 MG/0.1ML NA LIQD", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "72252050502", "type": "NDC" } ], "standard_charges": [ { "minimum": 355.8, "maximum": 1186.84, "gross_charge": 1262.6, "discounted_cash": 694.43, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 732.31, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 689.38, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1010.08, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1069.42, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 367.42, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 606.05, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 756.3, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 755.03, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1186.84, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1111.09, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 355.8, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1073.21, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 946.95, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 444.81, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 858.57, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1186.84, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 988.62, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 689.38, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1003.77, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 946.95, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1111.09, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 732.31, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 689.38, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DIAZEPAM 5 MG/ML IJ SOLN", "drug_information": { "unit": "2.000000", "type": "UN" }, "code_information": [ { "code": "00409127332_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 15.19, "maximum": 50.66, "gross_charge": 53.89, "discounted_cash": 29.64, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.26, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.42, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.11, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.64, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.68, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.87, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.28, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.23, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.66, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.42, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.19, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.81, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.42, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.99, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.65, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.66, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.2, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.42, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.84, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.42, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.42, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.26, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.42, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DIAZOXIDE 50 MG/ML PO SUSP", "drug_information": { "unit": "30.000000", "type": "UN" }, "code_information": [ { "code": "13517010030", "type": "NDC" } ], "standard_charges": [ { "minimum": 160.8, "maximum": 536.36, "gross_charge": 570.6, "discounted_cash": 313.83, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 330.95, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 311.55, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 456.48, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 483.3, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 166.04, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 273.89, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 341.79, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 341.22, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 536.36, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 502.13, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 160.8, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 485.01, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 427.95, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 201.02, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 388.01, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 536.36, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 446.78, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 311.55, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 453.63, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 427.95, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 502.13, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 330.95, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 311.55, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DIBUCAINE 1 % EX OINT", "drug_information": { "unit": "28.000000", "type": "GR" }, "code_information": [ { "code": "00536121195", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.1, "maximum": 7.0, "gross_charge": 7.45, "discounted_cash": 4.1, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.07, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.96, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.31, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.17, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.58, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.46, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.46, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.56, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.1, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.33, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.59, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.62, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.07, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.83, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.07, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.92, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.59, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.56, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.07, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DICLOFENAC POTASSIUM(MIGRAINE) 50 MG PO PACK", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "13913001203", "type": "NDC" } ], "standard_charges": [ { "minimum": 75.46, "maximum": 251.71, "gross_charge": 267.78, "discounted_cash": 147.28, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 155.31, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 146.21, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 214.22, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 226.81, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 77.92, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 128.53, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 160.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 160.13, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 251.71, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 235.65, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.46, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 227.61, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 200.84, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 94.34, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 182.09, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 251.71, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 209.67, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 146.21, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 212.89, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 200.84, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 235.65, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 155.31, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 146.21, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DICLOFENAC SODIUM 0.1 % OP SOLN", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "24208045705", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DICLOFENAC SODIUM 1 % EX GEL", "drug_information": { "unit": "100.000000", "type": "GR" }, "code_information": [ { "code": "45802095301", "type": "NDC" } ], "standard_charges": [ { "minimum": 6.72, "maximum": 22.4, "gross_charge": 23.83, "discounted_cash": 13.11, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.82, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.01, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.06, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.18, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.93, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.44, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.27, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.25, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.97, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.72, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.26, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.87, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.4, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.66, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.01, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.94, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.87, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.97, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.82, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.01, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DICLOFENAC SODIUM 25 MG PO TBEC", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "16571020310", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DICLOFENAC SODIUM 50 MG PO TBEC", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68001028006", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DICLOFENAC SODIUM 75 MG PO TBEC", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687065801", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DICLOFENAC-MISOPROSTOL 50-0.2 MG PO TBEC", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "59762002801", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.71, "maximum": 5.72, "gross_charge": 6.08, "discounted_cash": 3.34, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.53, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.32, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.86, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.15, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.77, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.64, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.64, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.72, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.35, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.71, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.56, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.14, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.13, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.72, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.76, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.32, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.83, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.56, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.35, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.53, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.32, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DICLOXACILLIN SODIUM 250 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00093312301", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DICLOXACILLIN SODIUM 500 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00093312501", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DICYCLOMINE HCL 10 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687036901", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", 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Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DICYCLOMINE HCL 10 MG/5ML PO SOLN", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "00603116158", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": 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total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DICYCLOMINE HCL 10 MG/ML IM SOLN", "drug_information": { "unit": "2.000000", "type": "UN" }, "code_information": [ { "code": "58914008052", "type": "NDC" } ], "standard_charges": [ { "minimum": 64.36, "maximum": 214.7, "gross_charge": 228.4, "discounted_cash": 125.62, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 132.47, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 124.71, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 182.72, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 193.45, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", 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"additional_payer_notes": "N/A", "standard_charge_dollar": 200.99, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 64.36, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 194.14, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 171.3, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 80.47, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 155.31, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 214.7, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 178.84, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 124.71, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 181.58, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 171.3, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 200.99, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 132.47, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 124.71, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DICYCLOMINE HCL 20 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687038001", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DIGOXIN 0.05 MG/ML PO SOLN", "drug_information": { "unit": "60.000000", "type": "UN" }, "code_information": [ { "code": "00054005746", "type": "NDC" } ], "standard_charges": [ { "minimum": 72.65, "maximum": 242.33, "gross_charge": 257.8, "discounted_cash": 141.79, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 149.52, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 140.76, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 206.24, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 218.36, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.02, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 123.74, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 154.42, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 154.16, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 242.33, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 226.86, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 72.65, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 219.13, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 193.35, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 90.82, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 175.3, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 242.33, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 201.86, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 140.76, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 204.95, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 193.35, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 226.86, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 149.52, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 140.76, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DIGOXIN 0.1 MG/ML IJ SOLN", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "70515026210", "type": "NDC" } ], "standard_charges": [ { "minimum": 123.03, "maximum": 410.4, "gross_charge": 436.6, "discounted_cash": 240.13, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 253.23, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 238.38, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 349.28, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 369.8, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 127.05, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 209.57, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 261.52, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 261.09, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 410.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 384.21, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 123.03, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 371.11, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 327.45, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 153.81, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 296.89, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 410.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 341.86, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 238.38, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 347.1, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 327.45, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 384.21, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 253.23, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 238.38, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DIGOXIN 0.25 MG/ML IJ SOLN", "drug_information": { "unit": "2.000000", "type": "UN" }, "code_information": [ { "code": "00641141035", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DIGOXIN 125 MCG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00904592161", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DIGOXIN 250 MCG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687055101", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DIGOXIN IMMUNE FAB 40 MG IV SOLR", "drug_information": { "unit": "4.000000", "type": "UN" }, "code_information": [ { "code": "50633012011", "type": "NDC" } ], "standard_charges": [ { "minimum": 2668.9, "maximum": 12216.16, "gross_charge": 12995.91, "discounted_cash": 7147.75, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 7537.63, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2668.9, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10396.73, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11007.54, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3781.81, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6238.04, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7784.55, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 7771.55, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12216.16, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11436.4, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3662.25, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11046.52, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9746.93, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 4578.46, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { 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"methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9746.93, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11436.4, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7537.63, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2668.9, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "DIHYDROERGOTAMINE MESYLATE 1 MG/ML IJ SOLN", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "81284041110", "type": "NDC" } ], "standard_charges": [ { "minimum": 27.85, "maximum": 92.91, "gross_charge": 98.84, "discounted_cash": 54.36, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 57.33, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 53.97, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 79.07, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 83.72, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.76, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.44, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.21, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.11, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 92.91, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.98, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.85, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 84.01, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.13, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.82, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 67.21, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 92.91, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 77.39, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 53.97, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 78.58, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.13, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.98, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 57.33, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 53.97, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DILAPAN-S SIZE 4 X 65MM", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "04444000035", "type": "NDC" } ], "standard_charges": [ { "minimum": 67.63, "maximum": 1158.0, "gross_charge": 240.0, "discounted_cash": 132.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 139.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 131.04, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 208.32, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 69.84, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 115.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 143.76, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 143.52, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 225.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 211.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 67.63, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 204.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 180.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 84.55, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 163.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 225.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 187.92, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 131.04, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 190.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 180.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 211.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 139.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 131.04, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Dilat xst trc ndurlgc px", "code_information": [ { "code": "50436", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2542.24, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1883.14, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 31454.77, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 57075.25, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2542.24, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 57075.25, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Dilat xst trc new access rcs", "code_information": [ { "code": "50437", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2542.24, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1883.14, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 28487.52, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 51691.19, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2542.24, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 51691.19, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Dilate esophagus", "code_information": [ { "code": "43453", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1398.27, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1035.76, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 8396.94, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 15236.4, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1398.27, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 15236.4, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Dilate esophagus 1/mult pass", "code_information": [ { "code": "43450", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 691.08, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 511.91, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 11937.57, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 21660.91, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 691.08, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 21660.91, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Dilate tear duct opening", "code_information": [ { "code": "68801", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 294.13, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 217.88, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 7493.24, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 13596.61, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 294.13, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 13596.61, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Dilate urethra stricture", "code_information": [ { "code": "53600", "type": "HCPCS" }, { "code": "53605", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2542.24, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 132.79, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1883.14, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 6579.06, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 11937.81, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 179.27, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2542.24, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 11937.81, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Dilation and curettage", "code_information": [ { "code": "58120", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2343.63, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1736.02, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 14202.72, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 26095.9, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2343.63, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 26095.9, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Dilation of anal sphincter", "code_information": [ { "code": "45905", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 869.1, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 643.78, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 9350.76, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 16967.1, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 869.1, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", 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"payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2343.63, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 13373.46, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Dilation of rectal narrowing", "code_information": [ { "code": "45910", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 869.1, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 643.78, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 5656.4, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 10263.62, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 869.1, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 10263.62, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Dilation of salivary duct", "code_information": [ { "code": "42650", "type": "HCPCS" }, { "code": "42660", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1091.85, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 808.78, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 278.05, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 13117.29, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 23801.54, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1091.85, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 375.37, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 23801.54, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Dilation of urethra", "code_information": [ { "code": "53665", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1509.96, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1118.49, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 8162.19, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 14835.44, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1509.96, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 14835.44, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Dilation of vagina", "code_information": [ { "code": "57400", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2343.63, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1736.02, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 7285.55, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 13219.74, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2343.63, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 13219.74, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DILTIAZEM 2 MG/ML SUSPENSION", "drug_information": { "unit": "60.000000", "type": "UN" }, "code_information": [ { "code": "08252000156", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DILTIAZEM 2% TOPICAL GEL", "drug_information": { "unit": "60.000000", "type": "GR" }, "code_information": [ { "code": "P5107974501", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.84, "maximum": 1158.0, "gross_charge": 6.54, "discounted_cash": 3.6, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.79, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.68, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.9, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.14, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.91, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.15, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.76, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.84, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.56, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.91, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.3, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.45, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.15, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.12, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.91, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.76, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.79, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DILTIAZEM HCL 120 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68682000910", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DILTIAZEM HCL 125 MG/25ML IV SOLN", "drug_information": { "unit": "25.000000", "type": "UN" }, "code_information": [ { "code": "00641601510", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 1158.0, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.72, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DILTIAZEM HCL 25 MG/5ML IV SOLN", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "00641601310", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 1158.0, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.72, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DILTIAZEM HCL 30 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687071701", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DILTIAZEM HCL 60 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687072801", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DILTIAZEM HCL 90 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "R0093032001", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DILTIAZEM HCL ER 120 MG PO CP12", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00378612001", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.73, "maximum": 5.76, "gross_charge": 6.13, "discounted_cash": 3.37, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.56, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.35, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.9, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.19, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.78, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.94, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.67, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.67, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.39, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.73, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.21, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.6, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.16, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.17, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.8, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.35, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.87, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.6, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.39, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.56, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.35, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DILTIAZEM HCL ER 60 MG PO CP12", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "51079092420", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.77, "maximum": 5.91, "gross_charge": 6.29, "discounted_cash": 3.46, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.65, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.43, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.03, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.33, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.83, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.02, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.77, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.91, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.54, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.77, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.35, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.72, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.22, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.28, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.91, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.93, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.43, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.72, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.54, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.65, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.43, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DILTIAZEM HCL ER 90 MG PO CP12", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "51079092520", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.09, "maximum": 6.96, "gross_charge": 7.4, "discounted_cash": 4.07, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.29, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.04, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.92, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.27, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.15, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.55, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.43, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.43, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.96, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.51, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.09, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.29, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.55, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.61, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.03, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.96, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.79, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.04, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.88, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.55, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.51, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.29, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.04, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DILTIAZEM HCL ER BEADS 120 MG PO CP24", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68682036790", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DILTIAZEM HCL ER COATED BEADS 120 MG PO CP24", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687019501", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DILTIAZEM HCL ER COATED BEADS 180 MG PO CP24", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687020601", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DILTIAZEM HCL ER COATED BEADS 240 MG PO CP24", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687021701", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DILTIAZEM HCL ER COATED BEADS 300 MG PO CP24", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687022801", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DIMETHYL FUMARATE 120 MG PO CPDR", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "16729041604", "type": "NDC" } ], "standard_charges": [ { "minimum": 3.42, "maximum": 11.4, "gross_charge": 12.13, "discounted_cash": 6.67, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.62, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.7, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.27, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.53, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.82, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.27, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.25, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.67, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.42, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.31, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.1, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.27, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.25, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.5, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.62, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.64, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.1, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.67, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.62, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DIMETHYL SULFOXIDE 50 % IS SOLN", "drug_information": { "unit": "50.000000", "type": "UN" }, "code_information": [ { "code": "67457017750", "type": "NDC" } ], "standard_charges": [ { "minimum": 390.88, "maximum": 1479.21, "gross_charge": 1573.63, "discounted_cash": 865.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 912.71, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 390.88, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1258.9, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1332.86, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 457.93, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 755.34, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 942.6, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 941.03, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1479.21, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1384.79, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 443.45, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1337.59, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1180.22, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 554.39, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1070.07, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1479.21, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1232.15, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 527.69, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1251.04, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1180.22, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1384.79, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 912.71, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 390.88, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "DINOPROSTONE 10 MG VA INST", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "55566280001", "type": "NDC" } ], "standard_charges": [ { "minimum": 534.94, "maximum": 1784.38, "gross_charge": 1898.28, "discounted_cash": 1044.05, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1101.0, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1036.46, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1518.62, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1607.84, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 552.4, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 911.17, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1137.07, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 1135.17, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1784.38, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1670.49, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 534.94, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1613.54, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1423.71, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 668.76, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1290.83, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1784.38, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1486.35, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1036.46, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1509.13, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1423.71, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1670.49, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1101.0, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1036.46, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DINUTUXIMAB 17.5 MG/5ML IV SOLN", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "66302001401", "type": "NDC" } ], "standard_charges": [ { "minimum": 11394.0, "maximum": 48874.72, "gross_charge": 51994.38, "discounted_cash": 28596.91, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 30156.74, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 28388.93, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 41595.5, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 44039.24, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15130.36, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 24957.3, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31144.63, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 11394.0, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 48874.72, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 45755.05, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14652.02, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 44195.22, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38995.79, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 18317.62, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 35356.18, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 48874.72, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 40711.6, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 28388.93, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 15189.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38995.79, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 45755.05, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 30156.74, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 28388.93, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DIPHENHYDRAMINE HCL 25 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00904723761", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DIPHENHYDRAMINE HCL 25 MG/10ML PO LIQD", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "81033000340", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DIPHENHYDRAMINE HCL 50 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00904205661", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DIPHENHYDRAMINE HCL 50 MG/ML IJ SOLN", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00641037625", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", 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"plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DIPHENHYDRAMINE HCL 50 MG/ML IJ SOLN (APHERESIS)", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00641037625_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DIPHENHYDRAMINE HCL 50 MG/ML IJ SOLN 1 ML VIAL (BULK CHARGE)", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00641037625_3", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DIPHENHYDRAMINE-ZINC ACETATE 1-0.1 % EX CREA", "drug_information": { "unit": "29.000000", "type": "GR" }, "code_information": [ { "code": "12547017162", "type": "NDC" } ], "standard_charges": [ { "minimum": 4.04, "maximum": 13.49, "gross_charge": 14.35, "discounted_cash": 7.89, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.48, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.15, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.18, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.89, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.6, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.58, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.49, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.63, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.04, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.2, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.76, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.06, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.76, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.49, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.24, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.41, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.76, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.63, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DIPHENHYDRAMINE-ZINC ACETATE 2-0.1 % EX CREA", "drug_information": { "unit": "28.000000", "type": "GR" }, "code_information": [ { "code": "45802035803", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.38, "maximum": 4.59, "gross_charge": 4.88, "discounted_cash": 2.68, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.83, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.66, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.9, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.13, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.42, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.34, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.59, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.29, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.38, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.15, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.66, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.72, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.32, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.59, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.82, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.66, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.88, "standard_charge_percentage": 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"drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "4306308904", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.25, "maximum": 7.52, "gross_charge": 8.0, "discounted_cash": 4.4, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.4, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.78, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.33, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.84, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.79, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.25, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.8, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.82, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.44, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.26, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.36, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DIPHENOXYLATE-ATROPINE 2.5-0.025 MG/5ML PO LIQD", "drug_information": { "unit": "60.000000", "type": "UN" }, "code_information": [ { "code": "00054319446", "type": "NDC" } ], "standard_charges": [ { "minimum": 44.67, "maximum": 148.99, "gross_charge": 158.5, "discounted_cash": 87.18, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 91.93, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.54, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 126.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 134.25, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.12, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 76.08, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 94.94, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 94.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 148.99, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 139.48, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 44.67, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 134.73, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 118.88, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.84, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 107.78, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 148.99, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 124.11, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.54, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 126.01, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 118.88, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 139.48, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 91.93, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.54, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DIPHTH-ACELL PERTUSSIS-TETANUS 15-23-5 LF-MCG/0.5 IM SUSP", "drug_information": { "unit": "0.500000", "type": "UN" }, "code_information": [ { "code": "49281028610", "type": "NDC" } ], "standard_charges": [ { "minimum": 18.15, "maximum": 60.55, "gross_charge": 64.41, "discounted_cash": 35.43, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.36, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.17, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 51.53, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.56, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.74, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.58, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.52, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.55, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 56.68, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.15, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.75, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 48.31, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.69, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.55, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.43, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.17, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 51.21, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 48.31, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 56.68, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.36, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.17, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DIPHTH-ACELL PERTUSSIS-TETANUS 25-58-10 LF-MCG/0.5 IM SUSP", "drug_information": { "unit": "0.500000", "type": "UN" }, "code_information": [ { "code": "58160081052", "type": "NDC" } ], "standard_charges": [ { "minimum": 14.48, "maximum": 48.3, "gross_charge": 51.38, "discounted_cash": 28.26, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.05, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.1, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.52, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.95, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.66, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.73, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 48.3, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.21, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.48, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.67, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.54, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.1, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.94, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 48.3, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.23, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.05, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.85, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.54, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.21, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.05, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DIPYRIDAMOLE 25 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00115107001", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DIPYRIDAMOLE 5 MG/ML IV SOLN", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "00641256944", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.76, "maximum": 39.24, "gross_charge": 41.74, "discounted_cash": 22.96, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.21, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.79, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.39, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.35, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.15, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.04, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.0, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.24, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.73, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.76, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.48, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.31, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.71, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.38, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.24, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.68, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.79, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.31, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.73, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.21, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.79, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DIPYRIDAMOLE 50 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00115107101", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DIPYRIDAMOLE 75 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00115107201", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Dise eval slp do brth flx dx", "code_information": [ { "code": "42975", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1271.11, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 941.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 4974.87, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 9027.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1271.11, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 9027.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DISOPYRAMIDE 10MG/ML SUSPENSION", "drug_information": { "unit": "15.000000", "type": "UN" }, "code_information": [ { "code": "P0591556101", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DISOPYRAMIDE PHOSPHATE 100 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00093312701", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DISOPYRAMIDE PHOSPHATE 150 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00093312901", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DISOPYRAMIDE PHOSPHATE ER 100 MG PO CP12", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00025273231", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.73, "maximum": 9.1, "gross_charge": 9.68, "discounted_cash": 5.32, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.61, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.29, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.74, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.2, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.82, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.65, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.8, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.79, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.1, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.73, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.23, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.26, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.58, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.1, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.58, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.29, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.7, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.26, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.61, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.29, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DISOPYRAMIDE PHOSPHATE ER 150 MG PO CP12", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00025274231", "type": "NDC" } ], "standard_charges": [ { "minimum": 3.22, "maximum": 10.75, "gross_charge": 11.44, "discounted_cash": 6.29, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.25, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.15, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.69, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.33, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.49, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.85, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.84, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.75, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.07, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.22, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.72, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.58, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.03, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.78, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.75, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.96, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.25, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.09, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.58, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.07, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.25, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Dist revas ligation hemo", "code_information": [ { "code": "36838", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 3984.54, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2951.51, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 9643.08, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 17497.53, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3984.54, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 17497.53, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DISULFIRAM 250 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "62135043130", "type": "NDC" } ], "standard_charges": [ { "minimum": 6.17, "maximum": 20.58, "gross_charge": 21.89, "discounted_cash": 12.04, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.7, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.95, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.51, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.54, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.37, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.51, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.11, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.09, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.58, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.26, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.17, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.61, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.42, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.71, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.89, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.58, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.14, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.95, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.4, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.42, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.26, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.7, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.95, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DIVALPROEX SODIUM 125 MG PO CSDR", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68084031301", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DIVALPROEX SODIUM 500 MG PO TBEC", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00832712401", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, 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"additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DIVALPROEX SODIUM ER 250 MG PO TB24", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "51079076608", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DIVALPROEX SODIUM ER 500 MG PO TB24", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68084041501", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Dlyd plmt xtn prosth 1st vsl", "code_information": [ { "code": "34710", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 26120.06, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 47395.25, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 47395.25, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DOBUTAMINE 2000 MCG/ML SYR FROM RTU (NICU)", "drug_information": { "unit": "250.000000", "type": "UN" }, "code_information": [ { "code": "00409234732", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DOBUTAMINE 500 MG/250 ML RTU (FIXED RATE)", "drug_information": { "unit": "250.000000", "type": "UN" }, "code_information": [ { "code": "00338107502", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DOBUTAMINE 500 MG/250 ML RTU (TITRATABLE RATE/ICU)", "drug_information": { "unit": "250.000000", "type": "UN" }, "code_information": [ { "code": "00338107502_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DOBUTAMINE HCL 12.5 MG/ML IV SOLN", "drug_information": { "unit": "20.000000", "type": "UN" }, "code_information": [ { "code": "00409234402", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DOBUTAMINE HCL 250 MG/20ML IV SOLN", "drug_information": { "unit": "20.000000", "type": "UN" }, "code_information": [ { "code": "00409234402_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DOBUTAMINE-DEXTROSE 1-5 MG/ML-% IV SOLN", "drug_information": { "unit": "250.000000", "type": "UN" }, "code_information": [ { "code": "00409234632", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DOCETAXEL 20 MG/ML IV CONC", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00143920401", "type": "NDC" } ], "standard_charges": [ { "minimum": 45.95, "maximum": 153.27, "gross_charge": 163.05, "discounted_cash": 89.68, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 94.57, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 89.03, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 130.44, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 138.1, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.45, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 78.26, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 97.67, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 97.5, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 153.27, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 143.48, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.95, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 138.59, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 122.29, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 57.44, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 110.87, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 153.27, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 127.67, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 89.03, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 129.62, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 122.29, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 143.48, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 94.57, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 89.03, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DOCETAXEL 80 MG/4ML IV CONC", "drug_information": { "unit": "4.000000", "type": "UN" }, "code_information": [ { "code": "25021024504", "type": "NDC" } ], "standard_charges": [ { "minimum": 22.33, "maximum": 74.5, "gross_charge": 79.25, "discounted_cash": 43.59, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.97, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.27, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.4, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 67.12, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.06, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.04, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.47, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.5, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 69.74, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.33, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 67.36, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.44, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.92, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 53.89, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.5, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 62.05, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.27, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.44, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 69.74, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.97, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.27, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DOCUSATE SODIUM 100 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00904718361", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DOCUSATE SODIUM 150 MG/15ML PO LIQD", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "00121187000", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DOCUSATE SODIUM 250 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "50268026815", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DOCUSATE SODIUM 50 MG/5ML PO LIQD", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "00121187000_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DOFETILIDE 125 MCG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00904668108", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.06, "maximum": 6.88, "gross_charge": 7.32, "discounted_cash": 4.03, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.25, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.0, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.86, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.2, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.13, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.51, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.38, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.38, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.88, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.44, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.06, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.22, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.49, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.58, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.98, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.88, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.73, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.0, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.82, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.49, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.44, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.25, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.0, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DOFETILIDE 250 MCG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "1671484101", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DOFETILIDE 500 MCG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "1671484201", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DOLUTEGRAVIR SODIUM 50 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "R4970222813", "type": "NDC" } ], "standard_charges": [ { "minimum": 44.41, "maximum": 148.13, "gross_charge": 157.58, "discounted_cash": 86.67, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 91.4, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.04, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 126.06, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 133.47, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.86, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.64, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 94.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 94.23, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 148.13, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 138.67, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 44.41, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 133.94, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 118.19, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.52, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 107.15, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 148.13, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 123.39, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.04, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 125.28, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 118.19, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 138.67, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 91.4, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.04, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DOLUTEGRAVIR-RILPIVIRINE 50-25 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "49702024213", "type": "NDC" } ], "standard_charges": [ { "minimum": 112.01, "maximum": 373.62, "gross_charge": 397.47, "discounted_cash": 218.61, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 230.53, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 217.02, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 317.98, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 336.66, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 115.66, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 190.79, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 238.08, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 237.69, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 373.62, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 349.77, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 112.01, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 337.85, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 298.1, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 140.03, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 270.28, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 373.62, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 311.22, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 217.02, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 315.99, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 298.1, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 349.77, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 230.53, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 217.02, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DONANEMAB-AZBT 350 MG/20ML IV SOLN", "drug_information": { "unit": "20.000000", "type": "UN" }, "code_information": [ { "code": "00002940101", "type": "NDC" } ], "standard_charges": [ { "minimum": 784.14, "maximum": 2615.64, "gross_charge": 2782.6, "discounted_cash": 1530.43, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1613.91, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1519.3, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2226.08, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2356.86, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 809.74, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1335.65, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1666.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 1663.99, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2615.64, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2448.69, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 784.14, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2365.21, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2086.95, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 980.31, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1892.17, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2615.64, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2178.78, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1519.3, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2212.17, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2086.95, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2448.69, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1613.91, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1519.3, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DONEPEZIL HCL 10 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00904647861", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DONEPEZIL HCL 5 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687029201", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DOPAMINE 1600 MCG/ML SYR FROM RTU (NICU)", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "08252000041", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DOPAMINE 400 MG/250 ML RTU (FIXED RATE)", "drug_information": { "unit": "250.000000", "type": "UN" }, "code_information": [ { "code": "00338100702", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DOPAMINE 400 MG/250 ML RTU (TITRATABLE RATE) (PERIPHERAL)", "drug_information": { "unit": "250.000000", "type": "UN" }, "code_information": [ { "code": "00338100702_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DOPAMINE 400 MG/250 ML RTU (TITRATABLE RATE/ICU)", "drug_information": { "unit": "250.000000", "type": "UN" }, "code_information": [ { "code": "00338100702_3", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DOPAMINE HCL 40 MG/ML IV SOLN", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "00409910420", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DORAVIRINE 100 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00006306901", "type": "NDC" } ], "standard_charges": [ { "minimum": 48.13, "maximum": 160.54, "gross_charge": 170.79, "discounted_cash": 93.93, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 99.06, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.25, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 136.63, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 144.66, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.7, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 81.98, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 102.3, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 102.13, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 160.54, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 150.3, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 48.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 145.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 128.09, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.17, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 116.14, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 160.54, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 133.73, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.25, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 135.78, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 128.09, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 150.3, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 99.06, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.25, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DORNASE ALFA 2.5 MG/2.5ML IN SOLN", "drug_information": { "unit": "2.500000", "type": "UN" }, "code_information": [ { "code": "50242010040", "type": "NDC" } ], "standard_charges": [ { "minimum": 82.87, "maximum": 276.44, "gross_charge": 294.08, "discounted_cash": 161.74, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 170.57, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 160.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 235.26, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 249.09, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 85.58, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 141.16, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 176.15, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 175.86, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 276.44, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 258.79, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.87, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 249.97, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 220.56, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.6, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 199.97, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 276.44, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 230.26, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 160.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 233.79, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 220.56, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 258.79, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 170.57, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 160.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DORZOLAMIDE HCL 2 % OP SOLN", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "24208048510", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DORZOLAMIDE HCL-TIMOLOL MAL 2-0.5 % OP SOLN", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "70069005101", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DORZOLAMIDE HCL-TIMOLOL MAL PF 2-0.5 % OP SOLN", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "50742032360", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DOSTARLIMAB-GXLY 500 MG/10ML IV SOLN", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "00173089803", "type": "NDC" } ], "standard_charges": [ { "minimum": 129.07, "maximum": 32608.0, "gross_charge": 34689.36, "discounted_cash": 19079.15, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 20119.83, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 129.07, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 27751.49, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 29381.89, "standard_charge_percentage": 85.0, "methodology": 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"standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30526.64, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 9775.46, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 29485.96, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 26017.02, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem 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129.07, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "DOUBLE ANTIBIOTIC 500-10000 UNIT/GM EX OINT", "drug_information": { "unit": "15.000000", "type": "GR" }, "code_information": [ { "code": "58980001205", "type": "NDC" } ], "standard_charges": [ { "minimum": 3.79, "maximum": 12.64, "gross_charge": 13.45, "discounted_cash": 7.4, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.34, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": 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"additional_payer_notes": "N/A", "standard_charge_dollar": 8.04, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.64, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.84, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.79, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.43, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.09, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.74, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.15, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.64, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.53, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.34, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.69, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.09, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.84, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.34, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DOXAZOSIN MESYLATE 1 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68084083601", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DOXAZOSIN MESYLATE 2 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68084085101", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DOXAZOSIN MESYLATE 4 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00904552461", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DOXEPIN HCL 10 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "51079043620", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DOXEPIN HCL 10 MG/ML PO CONC", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "54838051240", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DOXEPIN HCL 100 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "51079065120", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DOXEPIN HCL 25 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "51079043720", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DOXEPIN HCL 50 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "51079043820", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DOXORUBICIN 25 MG/ML SYRINGE FOR CHEMOEMBOLIZATION", "drug_information": { "unit": "2.000000", "type": "UN" }, "code_information": [ { "code": "00143927701", "type": "NDC" } ], "standard_charges": [ { "minimum": 242.95, "maximum": 810.39, "gross_charge": 862.12, "discounted_cash": 474.17, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 500.03, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 470.72, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 689.7, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 730.22, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 250.88, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 413.82, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 516.41, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 515.55, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 810.39, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 758.67, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 242.95, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 732.8, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 646.59, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 303.72, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 586.24, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 810.39, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 675.04, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 470.72, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 685.39, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 646.59, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 758.67, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 500.03, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 470.72, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DOXORUBICIN CHEMO SYRINGE", "drug_information": { "unit": "25.000000", "type": "UN" }, "code_information": [ { "code": "00069303220", "type": "NDC" } ], "standard_charges": [ { "minimum": 34.23, "maximum": 114.19, "gross_charge": 121.48, "discounted_cash": 66.81, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 70.46, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 66.33, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 97.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 102.89, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.35, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 58.31, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 72.77, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 72.65, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 114.19, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 106.9, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.23, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.26, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 91.11, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.8, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.61, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 114.19, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 95.12, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 66.33, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.58, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 91.11, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 106.9, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 70.46, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 66.33, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DOXORUBICIN HCL 10 MG IV SOLR", "drug_information": { "unit": "10.000000", "type": "ME" }, "code_information": [ { "code": "00143909201", "type": "NDC" } ], "standard_charges": [ { "minimum": 24.6, "maximum": 82.04, "gross_charge": 87.28, "discounted_cash": 48.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.62, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.65, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 69.82, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 73.93, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.4, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.89, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.28, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.19, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.04, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 76.81, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.6, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.19, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.46, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.35, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.04, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 68.34, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.65, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 69.39, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.46, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 76.81, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.62, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.65, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DOXORUBICIN HCL 50 MG IV SOLR", "drug_information": { "unit": "50.000000", "type": "ME" }, "code_information": [ { "code": "00143909301", "type": "NDC" } ], "standard_charges": [ { "minimum": 223.22, "maximum": 744.59, "gross_charge": 792.12, "discounted_cash": 435.67, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 459.43, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 432.5, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 633.7, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 670.93, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 230.51, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 380.22, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 474.48, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 473.69, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 744.59, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 697.07, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 223.22, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 673.3, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 594.09, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 279.06, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 538.64, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 744.59, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 620.23, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 432.5, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 629.74, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 594.09, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 697.07, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 459.43, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 432.5, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DOXORUBICIN HCL LIPOSOMAL 2 MG/ML IV SUSP", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "47335004940", "type": "NDC" } ], "standard_charges": [ { "minimum": 72.66, "maximum": 1532.46, "gross_charge": 1630.28, "discounted_cash": 896.65, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 945.56, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 72.66, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1304.22, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1380.85, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 474.41, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 782.53, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 976.54, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 974.91, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1532.46, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1434.65, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 459.41, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1385.74, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1222.71, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 574.35, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1108.59, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1532.46, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1276.51, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 98.09, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1296.07, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1222.71, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1434.65, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 945.56, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 72.66, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "DOXORUBICIN IN LC BEAD 100-300 MICRON", "drug_information": { "unit": "50.000000", "type": "ME" }, "code_information": [ { "code": "00143927701_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 242.95, "maximum": 810.39, "gross_charge": 862.12, "discounted_cash": 474.17, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 500.03, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 470.72, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 689.7, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 730.22, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 250.88, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 413.82, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 516.41, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 515.55, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 810.39, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 758.67, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 242.95, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 732.8, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 646.59, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 303.72, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 586.24, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 810.39, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 675.04, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 470.72, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 685.39, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 646.59, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 758.67, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 500.03, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 470.72, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DOXORUBICIN IN LC BEAD 300-500 MICRON", "drug_information": { "unit": "50.000000", "type": "ME" }, "code_information": [ { "code": "00143927701_3", "type": "NDC" } ], "standard_charges": [ { "minimum": 242.95, "maximum": 810.39, "gross_charge": 862.12, "discounted_cash": 474.17, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 500.03, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 470.72, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 689.7, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 730.22, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 250.88, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 413.82, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 516.41, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 515.55, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 810.39, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 758.67, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 242.95, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 732.8, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 646.59, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 303.72, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 586.24, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 810.39, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 675.04, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 470.72, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 685.39, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 646.59, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 758.67, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 500.03, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 470.72, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DOXORUBICIN IN LC BEAD 75-150 MICRON", "drug_information": { "unit": "50.000000", "type": "ME" }, "code_information": [ { "code": "00143927701_4", "type": "NDC" } ], "standard_charges": [ { "minimum": 242.95, "maximum": 810.39, "gross_charge": 862.12, "discounted_cash": 474.17, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 500.03, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 470.72, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 689.7, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 730.22, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 250.88, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 413.82, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 516.41, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 515.55, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 810.39, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 758.67, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 242.95, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 732.8, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 646.59, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 303.72, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 586.24, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 810.39, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 675.04, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 470.72, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 685.39, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 646.59, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 758.67, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 500.03, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 470.72, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DOXORUBICIN IN ONCOZENE MICROSPHERES 100 MICRON", "drug_information": { "unit": "50.000000", "type": "ME" }, "code_information": [ { "code": "00143927701_5", "type": "NDC" } ], "standard_charges": [ { "minimum": 242.95, "maximum": 810.39, "gross_charge": 862.12, "discounted_cash": 474.17, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 500.03, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 470.72, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 689.7, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 730.22, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 250.88, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 413.82, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 516.41, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 515.55, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 810.39, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 758.67, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 242.95, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 732.8, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 646.59, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 303.72, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 586.24, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 810.39, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 675.04, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 470.72, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 685.39, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 646.59, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 758.67, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 500.03, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 470.72, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DOXORUBICIN IN ONCOZENE MICROSPHERES 40 MICRON", "drug_information": { "unit": "50.000000", "type": "ME" }, "code_information": [ { "code": "00143927701_6", "type": "NDC" } ], "standard_charges": [ { "minimum": 242.95, "maximum": 810.39, "gross_charge": 862.12, "discounted_cash": 474.17, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 500.03, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 470.72, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 689.7, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 730.22, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 250.88, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 413.82, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 516.41, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 515.55, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 810.39, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 758.67, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 242.95, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 732.8, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 646.59, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 303.72, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 586.24, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 810.39, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 675.04, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 470.72, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 685.39, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 646.59, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 758.67, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 500.03, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 470.72, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DOXORUBICIN IN ONCOZENE MICROSPHERES 75 MICRON", "drug_information": { "unit": "50.000000", "type": "ME" }, "code_information": [ { "code": "00143927701_7", "type": "NDC" } ], "standard_charges": [ { "minimum": 242.95, "maximum": 810.39, "gross_charge": 862.12, "discounted_cash": 474.17, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 500.03, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 470.72, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 689.7, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 730.22, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 250.88, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 413.82, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 516.41, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 515.55, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 810.39, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 758.67, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 242.95, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 732.8, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 646.59, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 303.72, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 586.24, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 810.39, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 675.04, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 470.72, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 685.39, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 646.59, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 758.67, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 500.03, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 470.72, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DOXORUBICIN IN QUADRASPHERE", "drug_information": { "unit": "20.000000", "type": "UN" }, "code_information": [ { "code": "00143927701_8", "type": "NDC" } ], "standard_charges": [ { "minimum": 242.95, "maximum": 810.39, "gross_charge": 862.12, "discounted_cash": 474.17, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 500.03, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 470.72, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 689.7, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 730.22, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 250.88, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 413.82, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 516.41, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 515.55, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 810.39, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 758.67, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 242.95, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 732.8, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 646.59, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 303.72, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 586.24, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 810.39, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 675.04, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 470.72, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 685.39, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 646.59, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 758.67, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 500.03, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 470.72, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DOXYCYCLINE 40 MG PO CPDR", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00299382230", "type": "NDC" } ], "standard_charges": [ { "minimum": 19.44, "maximum": 64.85, "gross_charge": 68.99, "discounted_cash": 37.94, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.01, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.67, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.19, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 58.43, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.08, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.12, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.33, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.26, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 64.85, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.71, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.44, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 58.64, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 51.74, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.31, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.91, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 64.85, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.02, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.67, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.85, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 51.74, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.71, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.01, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.67, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DOXYCYCLINE 500 MG INTRAPLEURAL SYRINGE", "drug_information": { "unit": "50.000000", "type": "UN" }, "code_information": [ { "code": "67457043710", "type": "NDC" } ], "standard_charges": [ { "minimum": 63.82, "maximum": 1158.0, "gross_charge": 226.49, "discounted_cash": 124.57, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 131.36, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 123.66, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 196.59, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.91, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 108.72, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 135.67, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 135.44, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 212.9, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 199.31, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.82, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 192.52, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 169.87, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 79.79, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 154.01, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 212.9, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 177.34, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 123.66, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 180.06, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 169.87, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 199.31, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 131.36, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 123.66, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DOXYCYCLINE HYCLATE 100 MG IV SOLR", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "72266023705", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 1158.0, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.72, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DOXYCYCLINE HYCLATE 100 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "R0143314205", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DOXYCYCLINE HYCLATE 100 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "50268027915", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DOXYCYCLINE HYCLATE 150 MG PO TBEC", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "43547032410", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.0, "maximum": 6.68, "gross_charge": 7.11, "discounted_cash": 3.91, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.12, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.88, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.69, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.02, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.07, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.41, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.26, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.25, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.68, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.26, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.04, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.33, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.5, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.83, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.68, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.57, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.88, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.65, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.33, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.26, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.12, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.88, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DOXYCYCLINE HYCLATE 20 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "53489064701", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DOXYCYCLINE HYCLATE 50 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00143314150", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DOXYCYCLINE MONOHYDRATE 25 MG/5ML PO SUSR", "drug_information": { "unit": "60.000000", "type": "UN" }, "code_information": [ { "code": "68180065701", "type": "NDC" } ], "standard_charges": [ { "minimum": 8.6, "maximum": 28.7, "gross_charge": 30.53, "discounted_cash": 16.79, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.71, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.67, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.42, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.86, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.88, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.65, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.29, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.26, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.7, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.87, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.6, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.95, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.9, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.76, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.76, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.7, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.9, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.67, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.27, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.9, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.87, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.71, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.67, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DOXYLAMINE SUCCINATE (SLEEP) 25 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "41167000609", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Drain bl w/cath insertion", "code_information": [ { "code": "51102", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1509.96, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1118.49, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 8501.74, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 15436.04, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1509.96, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 15436.04, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Drain chest lesion", "code_information": [ { "code": "21502", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2391.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1771.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 14538.46, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 27190.37, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2391.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 27190.37, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Drain lower leg lesion", "code_information": [ { "code": "27603", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2109.62, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1562.68, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 4736.8, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 8595.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2109.62, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 8595.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Drain neck/chest lesion", "code_information": [ { "code": "21501", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2109.62, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1562.68, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 8037.67, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 14605.91, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2109.62, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 14605.91, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Drain spinal cord cyst", "code_information": [ { "code": "62268", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 656.23, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 486.1, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 2822.24, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 5121.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 656.23, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 5121.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Drain thigh/knee lesion", "code_information": [ { "code": "27301", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2109.62, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1562.68, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 8968.18, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 16272.9, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2109.62, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 16272.9, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Drain/inj joint/bursa w/o us", "code_information": [ { "code": "20600", "type": "HCPCS" }, { "code": "20605", "type": "HCPCS" }, { "code": "20610", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 217.58, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 982.08, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 1782.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 217.58, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 1782.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Drain/inj joint/bursa w/us", "code_information": [ { "code": "20611", "type": "HCPCS" }, { "code": "20604", "type": "HCPCS" }, { "code": "20606", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 510.46, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 161.17, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 753.92, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 1368.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 217.58, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 510.46, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 1368.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Drainage lymph node lesion", "code_information": [ { "code": "38300", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2109.62, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1562.68, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 8071.97, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 14646.73, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2109.62, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 14646.73, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Drainage of eye", "code_information": [ { "code": "65800", "type": "HCPCS" }, { "code": "65810", "type": "HCPCS" }, { "code": "65815", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1681.13, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1245.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 4815.29, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 8737.44, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1681.13, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 8737.44, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Drainage of finger abscess", "code_information": [ { "code": "26011", "type": "HCPCS" }, { "code": "26010", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1194.28, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 884.65, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 925.03, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 1678.5, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 146.46, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1194.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 1678.5, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Drainage of hydrocele", "code_information": [ { "code": "55000", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 518.62, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 384.16, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 8543.12, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 15501.67, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 518.62, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 15501.67, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Drainage of kidney lesion", "code_information": [ { "code": "50390", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 518.62, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 384.16, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 2616.16, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 4747.07, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 518.62, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 4747.07, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Drainage of mouth lesion", "code_information": [ { "code": "41018", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1091.85, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 808.78, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 11865.79, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 21530.7, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1091.85, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 21530.7, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Drainage of ovarian cyst(s)", "code_information": [ { "code": "58805", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2343.63, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1736.02, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 44263.32, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 81294.47, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2343.63, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 81294.47, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Drainage of pelvic abscess", "code_information": [ { "code": "57010", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2343.63, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1736.02, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 25169.79, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 45671.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2343.63, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 45671.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Drainage of salivary cyst", "code_information": [ { "code": "42409", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2390.47, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1770.72, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 14867.96, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 26978.15, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2390.47, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 26978.15, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Drainage of scrotum", "code_information": [ { "code": "54700", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1509.96, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1118.49, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 51389.88, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 93247.74, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1509.96, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 93247.74, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Dress/debrid p-thick burn s", "code_information": [ { "code": "16020", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 146.46, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 897.76, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 1629.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 146.46, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 1629.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Dressing change not for burn", "code_information": [ { "code": "15852", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 451.2, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 334.22, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 5339.68, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 9688.95, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 451.2, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 9688.95, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DRONABINOL 2.5 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687037521", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.56, "maximum": 8.54, "gross_charge": 9.09, "discounted_cash": 5.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.27, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.96, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.27, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.7, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.65, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.36, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.44, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.44, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.54, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.56, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.73, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.82, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.18, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.54, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.12, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.96, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.23, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.82, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.27, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.96, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DRONABINOL 5 MG/ML PO SOLN", "drug_information": { "unit": "0.420000", "type": "UN" }, "code_information": [ { "code": "78613020130", "type": "NDC" } ], "standard_charges": [ { "minimum": 8.34, "maximum": 27.81, "gross_charge": 29.59, "discounted_cash": 16.27, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.16, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.16, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.67, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.06, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.61, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.72, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.69, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.81, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.34, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.15, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.19, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.42, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.12, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.81, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.17, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.16, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.52, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.19, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.16, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.16, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DRONEDARONE HCL 400 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00024414260", "type": "NDC" } ], "standard_charges": [ { "minimum": 8.32, "maximum": 27.74, "gross_charge": 29.51, "discounted_cash": 16.23, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.12, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.11, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.61, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.99, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.59, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.16, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.68, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.65, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.74, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.97, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.32, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.08, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.13, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.4, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.07, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.74, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.11, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.11, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.46, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.13, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.97, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.12, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.11, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DROPERIDOL 2.5 MG/ML IJ SOLN", "drug_information": { "unit": "2.000000", "type": "UN" }, "code_information": [ { "code": "00517970225", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DROSPIREN-ETH ESTRAD-LEVOMEFOL 3-0.02-0.451 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "50419040703", "type": "NDC" } ], "standard_charges": [ { "minimum": 5.53, "maximum": 18.45, "gross_charge": 19.63, "discounted_cash": 10.8, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.39, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.72, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.7, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.63, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.71, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.42, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.76, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.74, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.45, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.27, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.53, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.69, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.72, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.92, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.35, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.45, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.37, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.72, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.61, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.72, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.27, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.39, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.72, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DROSPIRENONE-ETHINYL ESTRADIOL 3-0.02 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68180088673", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DROSPIRENONE-ETHINYL ESTRADIOL 3-0.03 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68180086873", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DROXIDOPA 100 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "63304008690", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DROXIDOPA 200 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "72205007390", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.22, "maximum": 4.07, "gross_charge": 4.33, "discounted_cash": 2.38, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.51, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.36, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.46, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.67, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.26, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.08, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.59, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.59, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.07, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.81, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.22, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.68, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.25, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.53, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.94, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.07, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.36, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.44, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.25, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.81, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.51, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.36, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DROXIDOPA 300 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "72205007490", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.83, "maximum": 6.1, "gross_charge": 6.49, "discounted_cash": 3.57, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.54, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.19, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.89, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.12, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.88, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.1, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.71, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.83, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.52, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.87, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.29, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.41, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.1, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.08, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.54, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.16, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.87, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.71, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.54, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Dstr mal les s/n/h/f/g .5 /<", "code_information": [ { "code": "17270", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 146.46, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 1542.55, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 2799.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 146.46, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 2799.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Dstr mal les s/n/h/f/g 0.6-1", "code_information": [ { "code": "17271", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 146.46, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 818.4, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 1485.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 146.46, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 1485.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Dstr mal les s/n/h/f/g 1.1-2", "code_information": [ { "code": "17272", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 146.46, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 1626.88, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 2952.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 146.46, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 2952.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Dstr mal ls f/e/e/n/l/m .5/<", "code_information": [ { "code": "17280", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 146.46, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 1016.8, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 1845.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 146.46, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 1845.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Dstr mal ls f/e/e/n/l/m .6-1", "code_information": [ { "code": "17281", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 146.46, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 1909.6, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 3465.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 146.46, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 3465.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Dstr mal ls f/e/e/n/l/m1.1-2", "code_information": [ { "code": "17282", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 146.46, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 2856.96, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 5184.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 146.46, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 5184.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Dstrj extensive retinopathy", "code_information": [ { "code": "67227", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2779.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2058.97, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 7809.52, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 14170.5, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2779.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 14170.5, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Dstrj mal les t/a/l .6-1.0cm", "code_information": [ { "code": "17261", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 146.46, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 947.36, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 1719.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 146.46, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 1719.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Dstrj mal les t/a/l 0.5 cm/<", "code_information": [ { "code": "17260", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 146.46, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 877.92, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 1593.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 146.46, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 1593.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Dstrj mal les t/a/l 1.1-2.0", "code_information": [ { "code": "17262", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 146.46, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 558.6, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 1013.58, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 146.46, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 1013.58, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Dstrj mal les t/a/l 2.1-3.0", "code_information": [ { "code": "17263", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 146.46, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 734.08, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 1332.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 146.46, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 1332.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Dstrj nulyt agt gnclr nrv", "code_information": [ { "code": "64624", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1439.39, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1066.21, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 2685.07, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 4872.11, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1439.39, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 4872.11, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DTAP-HEPATITIS B RECOMB-IPV IM SUSY", "drug_information": { "unit": "0.500000", "type": "UN" }, "code_information": [ { "code": "58160081152", "type": "NDC" } ], "standard_charges": [ { "minimum": 51.37, "maximum": 171.35, "gross_charge": 182.29, "discounted_cash": 100.26, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 105.73, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 99.53, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 145.83, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 154.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 53.05, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.5, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 109.19, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 109.01, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 171.35, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 160.42, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 51.37, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 154.95, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 136.72, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 64.22, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 123.96, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 171.35, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 142.73, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 99.53, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 144.92, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 136.72, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 160.42, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 105.73, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 99.53, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DTAP-IPV VACCINE 0.5 ML IM SUSY", "drug_information": { "unit": "0.500000", "type": "UN" }, "code_information": [ { "code": "58160081252", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.4, "maximum": 104.73, "gross_charge": 111.42, "discounted_cash": 61.28, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 64.62, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 89.14, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 94.37, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.42, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 53.48, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 66.74, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 66.63, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 104.73, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 98.05, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.4, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 94.71, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 83.57, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.25, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.77, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 104.73, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.24, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.58, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 83.57, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 98.05, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 64.62, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DULOXETINE HCL 20 MG PO CPEP", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687072321", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DULOXETINE HCL 30 MG PO CPEP", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687073401", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DULOXETINE HCL 60 MG PO CPEP", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687074501", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DUOBIOTIC ORTHOPEDIC IRRIGATION SOLN (OP USE) 500ML", "drug_information": { "unit": "500.000000", "type": "UN" }, "code_information": [ { "code": "08252036750", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 1158.0, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 95.48, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DUPILUMAB 300 MG/2ML SC SOSY", "drug_information": { "unit": "2.000000", "type": "UN" }, "code_information": [ { "code": "00024591401", "type": "NDC" } ], "standard_charges": [ { "minimum": 1456.02, "maximum": 4856.83, "gross_charge": 5166.84, "discounted_cash": 2841.76, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2996.77, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2821.09, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4133.47, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4376.31, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1503.55, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2480.08, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3094.94, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 3089.77, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4856.83, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4546.82, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1456.02, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4391.81, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3875.13, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1820.28, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3513.45, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4856.83, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4045.64, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2821.09, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4107.64, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3875.13, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4546.82, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2996.77, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2821.09, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DURVALUMAB 120 MG/2.4ML IV SOLN", "drug_information": { "unit": "2.400000", "type": "UN" }, "code_information": [ { "code": "00310450012", "type": "NDC" } ], "standard_charges": [ { "minimum": 1116.72, "maximum": 3725.03, "gross_charge": 3962.8, "discounted_cash": 2179.54, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2298.42, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2163.69, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3170.24, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3356.49, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1153.17, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1902.14, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2373.72, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2369.75, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3725.03, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3487.26, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1116.72, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3368.38, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2972.1, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1396.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2694.7, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3725.03, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3102.87, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2163.69, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3150.43, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2972.1, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3487.26, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2298.42, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2163.69, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "DUTASTERIDE 0.5 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "R3172213190", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Dx bone marrow aspirations", "code_information": [ { "code": "38220", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1194.28, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 9949.08, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 18052.76, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1194.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 18052.76, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Dx bone marrow biopsies", "code_information": [ { "code": "38221", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1194.28, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 7463.32, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 13542.3, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1194.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 13542.3, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Dx bone marrow bx & aspir", "code_information": [ { "code": "38222", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2109.62, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1562.68, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 9815.84, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 17811.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2109.62, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 17811.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Dx bronchoscope/brush", "code_information": [ { "code": "31623", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1271.11, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 941.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 8865.51, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 16086.6, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1271.11, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 16086.6, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Dx bronchoscope/lavage", "code_information": [ { "code": "31624", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1271.11, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 941.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 11699.18, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 21438.88, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1271.11, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 21438.88, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Dx bronchoscope/wash", "code_information": [ { "code": "31622", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1271.11, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 941.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 11230.69, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 20378.26, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1271.11, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 20378.26, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Dx laryngoscopy excl nb", "code_information": [ { "code": "31525", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1271.11, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 941.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 14327.47, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 25997.43, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1271.11, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 25997.43, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Dx laryngoscopy w/oper scope", "code_information": [ { "code": "31526", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1271.11, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 941.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 11974.35, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 21727.66, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1271.11, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 21727.66, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Dx lmbr spi pnxr", "code_information": [ { "code": "62270", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 510.46, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 378.12, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 5318.52, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 9650.58, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 510.46, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 9650.58, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Dx lmbr spi pnxr w/fluor/ct", "code_information": [ { "code": "62328", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 510.46, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 378.12, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 2290.76, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 4156.63, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 510.46, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 4156.63, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Ear cartilage graft", "code_information": [ { "code": "21235", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4360.43, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3229.95, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 16079.43, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 29176.38, "methodology": "percent of total billed charges" }, { 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"standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 8617.97, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 15687.62, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2390.47, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 15687.62, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ECALLANTIDE 10 MG/ML SC SOLN", "drug_information": { "unit": "3.000000", "type": "UN" }, "code_information": [ { "code": "47783010101_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 308.94, "maximum": 46937.3, "gross_charge": 49933.3, "discounted_cash": 27463.32, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 28961.31, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 308.94, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39946.64, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42293.51, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14530.59, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23967.98, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 29910.05, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 11394.0, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 46937.3, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 43941.3, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14071.2, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42443.31, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37449.98, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 17591.5, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 33954.64, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 46937.3, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 39097.77, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 417.07, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 15189.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37449.98, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 43941.3, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 28961.31, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 308.94, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "ECALLANTIDE 10 MG/ML SC SOLN|DISCARDED DRUG NOT ADMINISTERED", "drug_information": { "unit": "3.000000", "type": "UN" }, "code_information": [ { "code": "47783010101", "type": "NDC" } ], "standard_charges": [ { "minimum": 308.94, "maximum": 46871.5, "gross_charge": 49863.3, "discounted_cash": 27424.82, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 28920.71, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 308.94, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39890.64, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42234.22, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14510.22, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23934.38, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 29868.12, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 11394.0, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 46871.5, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 43879.7, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14051.48, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42383.81, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37397.48, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 17566.84, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 33907.04, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 46871.5, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 39042.96, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 417.07, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 15189.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37397.48, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 43879.7, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 28920.71, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 308.94, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "ECONAZOLE NITRATE 1 % EX CREA", "drug_information": { "unit": "15.000000", "type": "GR" }, "code_information": [ { "code": "45802046635", "type": "NDC" } ], "standard_charges": [ { "minimum": 4.22, "maximum": 14.08, "gross_charge": 14.98, "discounted_cash": 8.24, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.69, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.98, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.69, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.36, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.19, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.97, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.08, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.18, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.22, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.73, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.24, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.28, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.19, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.08, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.73, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.91, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.24, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.18, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.69, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Ecp ciliary body destruction", "code_information": [ { "code": "66711", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1681.13, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1245.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 5952.76, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 10801.38, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1681.13, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 10801.38, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ECULIZUMAB 300 MG/30ML IV SOLN", "drug_information": { "unit": "30.000000", "type": "UN" }, "code_information": [ { "code": "25682000101", "type": "NDC" } ], "standard_charges": [ { "minimum": 122.65, "maximum": 18394.86, "gross_charge": 19569.0, "discounted_cash": 10762.95, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 11350.02, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 122.65, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15655.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16574.94, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5694.58, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9393.12, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 11721.83, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 11394.0, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 18394.86, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17220.72, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 5514.54, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16633.65, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14676.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 6894.16, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 13306.92, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 18394.86, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 15322.53, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 165.57, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 15189.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14676.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17220.72, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 11350.02, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 122.65, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "EFAVIRENZ 600 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "31722050430", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.42, "maximum": 4.73, "gross_charge": 5.03, "discounted_cash": 2.77, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.92, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.75, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.02, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.26, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.46, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.41, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.01, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.01, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.73, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.43, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.42, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.28, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.77, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.77, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.42, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.73, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.94, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.75, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.77, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.43, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.92, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.75, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "EFGARTIGIMOD ALFA-FCAB 400 MG/20ML IV SOLN", "drug_information": { "unit": "20.000000", "type": "UN" }, "code_information": [ { "code": "73475304105", "type": "NDC" } ], "standard_charges": [ { "minimum": 5233.35, "maximum": 17456.87, "gross_charge": 18571.14, "discounted_cash": 10214.13, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 10771.26, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 10139.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14856.91, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15729.76, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5404.2, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8914.15, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 11124.11, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 11105.54, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17456.87, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16342.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 5233.35, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15785.47, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13928.36, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 6542.61, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 12628.38, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 17456.87, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 14541.2, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 10139.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 14764.06, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13928.36, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16342.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 10771.26, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 10139.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "EFGARTIGIMOD ALFA-HYALUR-QVFC 180-2000 MG-UNIT/ML SC SOLN", "drug_information": { "unit": "5.600000", "type": "UN" }, "code_information": [ { "code": "73475310203", "type": "NDC" } ], "standard_charges": [ { "minimum": 18.09, "maximum": 45369.46, "gross_charge": 48265.38, "discounted_cash": 26545.96, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 27993.92, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.09, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38612.3, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 40880.78, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14045.23, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23167.38, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 28910.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 11394.0, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 45369.46, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42473.53, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 13601.18, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 41025.57, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 36199.04, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 17003.89, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 32820.46, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 45369.46, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 37791.79, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.42, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 15189.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 36199.04, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42473.53, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 27993.92, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.09, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "Egd balloon dil esoph30 mm/>", "code_information": [ { "code": "43233", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1398.27, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1035.76, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 4589.08, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 8326.96, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1398.27, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 8326.96, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Egd biopsy single/multiple", "code_information": [ { "code": "43239", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 691.08, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 511.91, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 3581.12, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 6498.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 691.08, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 6498.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Egd cautery tumor polyp", "code_information": [ { "code": "43250", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1398.27, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1035.76, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 8108.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 14712.08, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1398.27, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 14712.08, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Egd control bleeding any", "code_information": [ { "code": "43255", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1398.27, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1035.76, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 6522.42, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 11835.05, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1398.27, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 11835.05, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Egd diagnostic brush wash", "code_information": [ { "code": "43235", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 691.08, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 511.91, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 2777.6, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 5040.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 691.08, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 5040.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Egd dilate stricture", "code_information": [ { "code": "43245", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1398.27, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1035.76, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 4472.02, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 8114.56, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1398.27, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 8114.56, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Egd endo mucosal resection", "code_information": [ { "code": "43254", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1398.27, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1035.76, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 5485.08, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 9952.76, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1398.27, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 9952.76, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Egd endoscopic stent place", "code_information": [ { "code": "43266", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4387.82, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3250.23, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 10983.3, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 19929.41, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4387.82, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 19929.41, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Egd esophagogastrc fndoplsty", "code_information": [ { "code": "43210", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 7674.11, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5684.53, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 19911.85, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 36130.39, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7674.11, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 36130.39, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Egd guide wire insertion", "code_information": [ { "code": "43248", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 691.08, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 511.91, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 3791.92, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 6880.5, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 691.08, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 6880.5, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Egd injection varices", "code_information": [ { "code": "43243", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1398.27, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1035.76, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 4265.05, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 7739.01, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1398.27, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 7739.01, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Egd lesion ablation", "code_information": [ { "code": "43270", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1398.27, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1035.76, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 8195.66, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 14871.15, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1398.27, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 14871.15, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Egd place gastrostomy tube", "code_information": [ { "code": "43246", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1398.27, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1035.76, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 4492.42, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 8151.59, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1398.27, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 8151.59, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Egd remove foreign body", "code_information": [ { "code": "43247", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 691.08, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 511.91, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 4582.58, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 8315.18, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 691.08, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 8315.18, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Egd remove lesion snare", "code_information": [ { "code": "43251", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1398.27, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1035.76, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 3169.44, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 7425.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1398.27, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 7425.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Egd tube/cath insertion", "code_information": [ { "code": "43241", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1398.27, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1035.76, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 3763.15, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 6828.3, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1398.27, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 6828.3, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Egd us exam duodenum/jejunum", "code_information": [ { "code": "43259", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1398.27, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1035.76, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 3988.61, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 7516.39, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1398.27, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 7516.39, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Egd us fine needle bx/aspir", "code_information": [ { "code": "43238", "type": "HCPCS" }, { "code": "43242", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1398.27, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1035.76, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 5800.8, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 10525.64, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1398.27, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 10525.64, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Egd us transmural injxn/mark", "code_information": [ { "code": "43253", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1398.27, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1035.76, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 8655.42, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 15705.4, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1398.27, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 15705.4, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Egd varices ligation", "code_information": [ { "code": "43244", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1398.27, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1035.76, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 2752.8, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 4995.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1398.27, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 4995.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Egd w/thrml txmnt gerd", "code_information": [ { "code": "43257", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2804.32, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2077.27, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 9267.76, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 16816.5, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2804.32, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 16816.5, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Egd w/transmural drain cyst", "code_information": [ { "code": "43240", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4387.82, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3250.23, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 13208.56, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 23967.15, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4387.82, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 23967.15, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Elbow arthroscopy/surgery", "code_information": [ { "code": "29834", "type": "HCPCS" }, { "code": "29835", "type": "HCPCS" }, { "code": "29837", "type": "HCPCS" }, { "code": "29838", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2391.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1771.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 9409.87, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 17074.37, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2391.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 17074.37, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ELETRIPTAN HYDROBROMIDE 20 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68382092286", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.92, "maximum": 9.74, "gross_charge": 10.36, "discounted_cash": 5.7, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.01, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.66, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.29, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.77, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.97, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.21, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.2, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.74, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.12, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.92, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.81, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.77, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.65, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.74, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.11, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.66, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.24, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.77, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.12, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.01, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.66, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ELETRIPTAN HYDROBROMIDE 40 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00049234045", "type": "NDC" } ], "standard_charges": [ { "minimum": 61.69, "maximum": 205.79, "gross_charge": 218.93, "discounted_cash": 120.41, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 126.98, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 119.54, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 175.14, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 185.43, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.71, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 105.09, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 131.14, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 130.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 205.79, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 192.66, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.69, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 186.09, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 164.2, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 77.13, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 148.87, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 205.79, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 171.42, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 119.54, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 174.05, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 164.2, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 192.66, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 126.98, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 119.54, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ELLIOTTS B IT SOLN", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "55792000710", "type": "NDC" } ], "standard_charges": [ { "minimum": 78.1, "maximum": 260.5, "gross_charge": 277.13, "discounted_cash": 152.42, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 160.74, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 151.31, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 221.7, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 234.73, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 80.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 133.02, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 166.0, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 165.72, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 260.5, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 243.87, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 78.1, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 235.56, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 207.85, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 97.63, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 188.45, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 260.5, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 216.99, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 151.31, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 220.32, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 207.85, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 243.87, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 160.74, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 151.31, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ELOTUZUMAB 300 MG IV SOLR", "drug_information": { "unit": "12.000000", "type": "UN" }, "code_information": [ { "code": "00003229111", "type": "NDC" } ], "standard_charges": [ { "minimum": 1886.12, "maximum": 6291.53, "gross_charge": 6693.12, "discounted_cash": 3681.22, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3882.01, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3654.44, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5354.5, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5669.07, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1947.7, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3212.7, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4009.18, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4002.49, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6291.53, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5889.95, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1886.12, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5689.15, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5019.84, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2357.99, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4551.32, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6291.53, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5240.71, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3654.44, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5321.03, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5019.84, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5889.95, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3882.01, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3654.44, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ELRANATAMAB-BCMM 44 MG/1.1ML SC SOLN", "drug_information": { "unit": "0.300000", "type": "UN" }, "code_information": [ { "code": "00069252202", "type": "NDC" } ], "standard_charges": [ { "minimum": 6636.69, "maximum": 22137.99, "gross_charge": 23551.05, "discounted_cash": 12953.08, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 13659.61, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 12858.87, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 18840.84, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19947.74, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6853.36, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11304.5, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 14107.08, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 11394.0, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 22137.99, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20724.92, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 6636.69, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20018.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17663.29, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 8297.03, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 16014.71, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 22137.99, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 18440.47, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 12858.87, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 15189.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17663.29, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20724.92, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 13659.61, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 12858.87, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ELRANATAMAB-BCMM 76 MG/1.9ML SC SOLN", "drug_information": { "unit": "1.900000", "type": "UN" }, "code_information": [ { "code": "00069449402", "type": "NDC" } ], "standard_charges": [ { "minimum": 97.65, "maximum": 38238.35, "gross_charge": 40679.1, "discounted_cash": 22373.51, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23593.88, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 97.65, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32543.28, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34455.2, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11837.62, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19525.97, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 24366.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 11394.0, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38238.35, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35797.61, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11463.37, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34577.24, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30509.33, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14331.25, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27661.79, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 38238.35, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31851.74, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 131.83, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 15189.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30509.33, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35797.61, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23593.88, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 97.65, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "ELTROMBOPAG OLAMINE 25 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00078068515", "type": "NDC" } ], "standard_charges": [ { "minimum": 238.24, "maximum": 794.71, "gross_charge": 845.44, "discounted_cash": 464.99, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 490.36, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 461.61, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 676.35, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 716.09, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 246.02, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 405.81, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 506.42, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 505.57, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 794.71, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 743.99, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 238.24, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 718.62, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 634.08, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 297.85, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 574.9, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 794.71, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 661.98, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { 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"methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 461.61, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ELTROMBOPAG OLAMINE 75 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00078068715", "type": "NDC" } ], "standard_charges": [ { "minimum": 739.11, "maximum": 2465.46, "gross_charge": 2622.83, "discounted_cash": 1442.56, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1521.24, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1432.07, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2098.26, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2221.54, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 763.24, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1258.96, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", 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charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2229.41, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1967.12, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 924.02, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1783.52, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", 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billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 286.06, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 395.44, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 329.39, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 229.69, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 334.44, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 315.51, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 370.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 243.99, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 229.69, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ELVITEG-COBIC-EMTRICIT-TENOFDF 150-150-200-300 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "61958120101", "type": "NDC" } ], "standard_charges": [ { "minimum": 124.36, "maximum": 414.81, "gross_charge": 441.29, "discounted_cash": 242.71, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 255.95, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 240.94, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 353.03, "standard_charge_percentage": 80.0, "methodology": "percent of total 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"methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 414.81, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 388.34, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 124.36, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 375.1, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 330.97, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 155.47, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 300.08, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 414.81, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 345.53, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 240.94, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 350.83, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 330.97, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 388.34, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 255.95, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 240.94, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "EMAPALUMAB-LZSG 100 MG/20ML IV SOLN", "drug_information": { "unit": "20.000000", "type": "UN" }, "code_information": [ { "code": "66658051001", "type": "NDC" } ], "standard_charges": [ { "minimum": 206.4, "maximum": 95231.68, "gross_charge": 101310.3, "discounted_cash": 55720.67, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 58759.97, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 206.4, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 81048.24, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 85809.82, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 29481.3, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 48628.94, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 60684.87, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 11394.0, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 95231.68, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 89153.06, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 28549.24, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 86113.76, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 75982.73, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 35691.62, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 68891.0, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", 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"additional_payer_notes": "N/A", "standard_charge_dollar": 89153.06, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 58759.97, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 206.4, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "EMAPALUMAB-LZSG 50 MG/10ML IV SOLN", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "66658050501", "type": "NDC" } ], "standard_charges": [ { "minimum": 206.4, "maximum": 47615.84, "gross_charge": 50655.15, "discounted_cash": 27860.33, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 29379.99, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 206.4, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 40524.12, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42904.91, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14740.65, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 24314.47, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 30342.43, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 11394.0, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 47615.84, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 44576.53, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14274.62, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 43056.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37991.36, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 17845.81, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { 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"methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37991.36, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 44576.53, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 29379.99, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 206.4, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "EMPAGLIFLOZIN 10 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00597015237", "type": "NDC" } ], "standard_charges": [ { "minimum": 8.58, "maximum": 28.61, "gross_charge": 30.44, "discounted_cash": 16.74, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.66, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.62, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.35, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.78, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.86, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.61, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.23, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.2, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.61, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.79, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.58, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.87, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.83, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.72, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.7, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.61, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.83, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.62, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.83, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.79, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.66, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.62, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "EMPAGLIFLOZIN 25 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00597015337", "type": "NDC" } ], "standard_charges": [ { "minimum": 8.58, "maximum": 28.61, "gross_charge": 30.44, "discounted_cash": 16.74, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.66, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.62, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.35, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.78, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.86, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.61, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.23, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.2, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.61, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.79, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.58, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.87, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.83, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.72, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.7, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.61, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.83, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.62, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.83, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.79, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.66, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.62, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "EMTRICITAB-RILPIVIR-TENOFOV AF 200-25-25 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "61958210101", "type": "NDC" } ], "standard_charges": [ { "minimum": 107.89, "maximum": 359.88, "gross_charge": 382.85, "discounted_cash": 210.57, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 222.05, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 209.04, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 306.28, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 324.27, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 111.41, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 183.77, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 229.33, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 228.94, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 359.88, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 336.91, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 107.89, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 325.42, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 287.14, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 134.88, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 260.34, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 359.88, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 299.77, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 209.04, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 304.37, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 287.14, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 336.91, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 222.05, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 209.04, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "EMTRICITAB-RILPIVIR-TENOFOV DF 200-25-300 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "61958110101", "type": "NDC" } ], "standard_charges": [ { "minimum": 107.89, "maximum": 359.88, "gross_charge": 382.85, "discounted_cash": 210.57, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 222.05, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 209.04, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 306.28, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 324.27, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 111.41, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 183.77, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 229.33, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 228.94, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 359.88, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 336.91, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 107.89, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 325.42, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 287.14, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 134.88, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 260.34, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 359.88, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 299.77, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 209.04, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 304.37, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 287.14, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 336.91, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 222.05, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 209.04, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "EMTRICITABINE 10 MG/ML PO SOLN", "drug_information": { "unit": "170.000000", "type": "UN" }, "code_information": [ { "code": "61958060201", "type": "NDC" } ], "standard_charges": [ { "minimum": 80.85, "maximum": 269.69, "gross_charge": 286.9, "discounted_cash": 157.8, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 166.4, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 156.65, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 229.52, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 243.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 83.49, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 137.71, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 171.85, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 171.57, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 269.69, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 252.47, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 80.85, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 243.87, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 215.18, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 101.07, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 195.09, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 269.69, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 224.64, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 156.65, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 228.09, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 215.18, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 252.47, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 166.4, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 156.65, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "EMTRICITABINE 200 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "65862030130", "type": "NDC" } ], "standard_charges": [ { "minimum": 8.59, "maximum": 28.67, "gross_charge": 30.5, "discounted_cash": 16.78, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.69, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.65, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.4, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.83, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.88, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.64, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.27, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.24, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.67, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.84, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.59, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.93, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.88, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.74, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.67, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.88, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.65, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.25, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.88, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.84, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.69, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.65, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "EMTRICITABINE-TENOFOVIR AF 200-25 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "61958200202", "type": "NDC" } ], "standard_charges": [ { "minimum": 56.21, "maximum": 187.49, "gross_charge": 199.46, "discounted_cash": 109.7, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 115.69, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 108.91, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 159.57, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 168.94, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 58.04, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 95.74, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 119.48, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 119.28, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 187.49, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 175.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 56.21, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 169.54, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 149.6, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 70.27, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 135.63, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 187.49, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 156.18, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 108.91, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 158.57, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 149.6, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 175.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 115.69, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 108.91, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "EMTRICITABINE-TENOFOVIR DF 200-300 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687071925", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ENALAPRIL MALEATE 1 MG/ML PO SOLN", "drug_information": { "unit": "150.000000", "type": "UN" }, "code_information": [ { "code": "31722002015", "type": "NDC" } ], "standard_charges": [ { "minimum": 140.34, "maximum": 468.15, "gross_charge": 498.03, "discounted_cash": 273.92, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 288.86, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 271.92, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 398.42, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 421.83, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 144.93, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 239.05, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 298.32, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 297.82, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 468.15, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 438.27, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 140.34, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 423.33, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 373.52, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 175.46, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 338.66, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 468.15, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 389.96, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 271.92, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 395.93, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 373.52, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 438.27, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 288.86, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 271.92, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ENALAPRIL MALEATE 10 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "R4354754710", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ENALAPRIL MALEATE 20 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "1671444501", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ENALAPRIL MALEATE 5 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "R4354754610", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ENALAPRILAT 0.125 MG/ML SYRINGE (PEDS)", "drug_information": { "unit": "2.000000", "type": "UN" }, "code_information": [ { "code": "00143978610", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 1158.0, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.72, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ENALAPRILAT 1.25 MG/ML IV SOLN", "drug_information": { "unit": "2.000000", "type": "UN" }, "code_information": [ { "code": "00143978610_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 1158.0, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.72, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Endo cholangiopancreatograph", "code_information": [ { "code": "43261", "type": "HCPCS" }, { "code": "43262", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2804.32, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2077.27, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 10595.67, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 21850.99, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2804.32, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 21850.99, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Endo sleeve gastro w/tube", "code_information": [ { "code": "C9784", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 7674.11, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5684.53, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 8526.37, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 15471.24, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7674.11, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 15471.24, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Endocerv curettage w/scope", "code_information": [ { "code": "57456", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 224.22, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 1079.29, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 1958.4, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 224.22, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 1958.4, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Endocervical curettage", "code_information": [ { "code": "57505", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 641.82, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 475.42, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 14323.25, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 25989.76, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 641.82, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 25989.76, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Endoscopic injection/implant", "code_information": [ { "code": "51715", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2542.24, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1883.14, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 13962.76, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 25335.65, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2542.24, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 25335.65, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Endoscopic us exam esoph", "code_information": [ { "code": "43237", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1398.27, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1035.76, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 4427.6, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 8033.95, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1398.27, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 8033.95, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Endoscopy bowel pouch/biop", "code_information": [ { "code": "44386", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 672.02, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 497.79, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 3521.6, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 6390.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 672.02, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 6390.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Endoscopy maxillary sinus", "code_information": [ { "code": "31267", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 5102.55, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3779.67, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 19207.08, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 34851.57, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5102.55, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 34851.57, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Endoscopy of bowel pouch", "code_information": [ { "code": "44385", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 672.02, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 497.79, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 3253.76, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 5904.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 672.02, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 5904.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Endoscopy of ureter", "code_information": [ { "code": "50951", "type": "HCPCS" }, { "code": "50953", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2542.24, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1883.14, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 10350.58, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 18781.3, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2542.24, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 18781.3, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Endovasc taa repr w/o subcl", "code_information": [ { "code": "33881", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 24499.25, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 44454.31, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 44454.31, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Endovasc tempory vessel occl", "code_information": [ { "code": "61623", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 8359.13, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 6191.95, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 32505.63, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 58981.99, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8359.13, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 58981.99, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Endovenous rf 1st vein", "code_information": [ { "code": "36475", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2320.02, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1718.54, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 11138.25, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 20480.54, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2320.02, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 20480.54, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ENEMA 7-19 GM/118ML RE ENEM", "drug_information": { "unit": "133.000000", "type": "UN" }, "code_information": [ { "code": "00536741551", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ENFORTUMAB VEDOTIN-EJFV 20 MG IV SOLR", "drug_information": { "unit": "2.000000", "type": "UN" }, "code_information": [ { "code": "51144002001", "type": "NDC" } ], "standard_charges": [ { "minimum": 20.06, "maximum": 7921.38, "gross_charge": 8427.0, "discounted_cash": 4634.85, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4887.66, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.06, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6741.6, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7137.67, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2452.26, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4044.96, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5047.77, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 5039.35, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7921.38, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7415.76, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2374.73, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7162.95, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6320.25, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2968.83, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5730.36, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7921.38, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6598.34, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.08, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6699.47, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6320.25, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7415.76, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4887.66, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.06, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "ENFUVIRTIDE 90 MG SC SOLR", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00004038140", "type": "NDC" } ], "standard_charges": [ { "minimum": 45.65, "maximum": 152.26, "gross_charge": 161.98, "discounted_cash": 89.09, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.95, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.44, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" 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Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, 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}, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", 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"additional_generic_notes": "" } ] }, { "description": "ENOXAPARIN SODIUM 150 MG/ML IJ SOSY", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "71288043894", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, 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"standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ENOXAPARIN SODIUM 30 MG/0.3ML IJ SOSY", "drug_information": { "unit": "0.300000", "type": "UN" }, "code_information": [ { "code": "71288043281", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", 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"additional_payer_notes": "N/A", "standard_charge_dollar": 26.27, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.73, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.24, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.37, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.18, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.74, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.13, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.09, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.58, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.86, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.77, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.51, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.98, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.96, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.58, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.47, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.73, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.01, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.98, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.86, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.27, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.73, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ENOXAPARIN SODIUM 300 MG/3ML IJ SOLN SPLIT SYRINGE", "drug_information": { "unit": "3.000000", "type": "UN" }, "code_information": [ { "code": "00548560800", "type": "NDC" } ], "standard_charges": [ { "minimum": 20.42, "maximum": 68.13, "gross_charge": 72.48, "discounted_cash": 39.86, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.04, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 57.98, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.09, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.79, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.42, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.34, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 68.13, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.78, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.42, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.61, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.36, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.53, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.29, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 68.13, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 56.75, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 57.62, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.36, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.78, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.04, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ENOXAPARIN SODIUM 40 MG/0.4ML IJ SOSY", "drug_information": { "unit": "0.400000", "type": "UN" }, "code_information": [ { "code": "71288043383", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ENOXAPARIN SODIUM 80 MG/0.8ML IJ SOSY", "drug_information": { "unit": "0.800000", "type": "UN" }, "code_information": [ { "code": "71288043587", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ENTACAPONE 200 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687018821", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.03, "maximum": 6.77, "gross_charge": 7.2, "discounted_cash": 3.96, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.18, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.93, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.76, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.1, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.1, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.46, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.31, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.31, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.77, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.34, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.03, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.12, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.4, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.54, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.9, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.77, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.64, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.93, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.72, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.4, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.34, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.18, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.93, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ENTECAVIR 0.05 MG/ML PO SOLN", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "00003161412", "type": "NDC" } ], "standard_charges": [ { "minimum": 29.19, "maximum": 97.37, "gross_charge": 103.59, "discounted_cash": 56.97, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.08, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 56.56, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.87, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.74, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.14, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.72, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 62.05, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.95, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 97.37, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 91.16, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.19, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.05, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 77.69, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.49, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 70.44, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 97.37, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 81.11, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 56.56, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.35, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 77.69, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 91.16, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.08, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 56.56, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ENTECAVIR 0.5 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687021625", "type": "NDC" } ], "standard_charges": [ { "minimum": 7.04, "maximum": 23.48, "gross_charge": 24.98, "discounted_cash": 13.74, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.49, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.64, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.98, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.16, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.27, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.99, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.94, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.48, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.98, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.23, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.74, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.8, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.99, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.48, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.56, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.64, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.86, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.74, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.98, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.49, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.64, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "EPCORITAMAB-BYSP 4 MG/0.8ML SC SOLN", "drug_information": { "unit": "0.800000", "type": "UN" }, "code_information": [ { "code": "82705000201", "type": "NDC" } ], "standard_charges": [ { "minimum": 29.58, "maximum": 3722.48, "gross_charge": 3960.09, "discounted_cash": 2178.05, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2296.85, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.58, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3168.07, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3354.2, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1152.39, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1900.84, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2372.09, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2368.13, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3722.48, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3484.88, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1115.95, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3366.08, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2970.07, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1395.14, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2692.86, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3722.48, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3100.75, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.93, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3148.27, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2970.07, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3484.88, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2296.85, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.58, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "EPCORITAMAB-BYSP 48 MG/0.8ML SC SOLN", "drug_information": { "unit": "0.800000", "type": "UN" }, "code_information": [ { "code": "82705001001", "type": "NDC" } ], "standard_charges": [ { "minimum": 11394.0, "maximum": 42936.08, "gross_charge": 45676.68, "discounted_cash": 25122.17, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 26492.47, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 24939.47, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 36541.34, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38688.15, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13291.91, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21924.81, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27360.33, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 11394.0, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42936.08, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 40195.48, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 12871.69, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38825.18, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34257.51, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 16091.89, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31060.14, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 42936.08, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 35764.84, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24939.47, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 15189.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34257.51, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 40195.48, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 26492.47, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24939.47, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "EPHEDRINE SULFATE (PRESSORS) 25 MG/5ML IV SOSY", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "69374090105", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.94, "maximum": 39.84, "gross_charge": 42.38, "discounted_cash": 23.31, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.58, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.14, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.9, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.9, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.33, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.34, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.34, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.84, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.29, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.94, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.02, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.79, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.93, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.82, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.84, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.18, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.14, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.69, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.79, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.29, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.58, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.14, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "EPHEDRINE SULFATE (PRESSORS) 5 MG/ML IV SOLN", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "14789025010", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "EPHEDRINE SULFATE (PRESSORS) 50 MG/ML IV SOLN", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "51754420004", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 1158.0, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.72, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "EPINEPHRINE (ANAPHYLAXIS) 30 MG/30ML IJ SOLN", "drug_information": { "unit": "0.300000", "type": "UN" }, "code_information": [ { "code": "76329906000", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", 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billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "EPINEPHRINE (ANAPHYLAXIS) PF 1 MG/ML IJ SOLN", "drug_information": { "unit": "0.300000", "type": "UN" }, "code_information": [ { "code": "54288010310_3", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "EPINEPHRINE 0.15 MG/0.3ML IJ SOAJ", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "49502010102", "type": "NDC" } ], "standard_charges": [ { "minimum": 127.3, "maximum": 1158.0, "gross_charge": 451.73, "discounted_cash": 248.45, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 262.0, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 246.64, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 392.1, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 131.45, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 216.83, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 270.59, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 270.13, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 424.63, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 397.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 127.3, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 383.97, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 338.8, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 159.14, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 307.18, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 424.63, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 353.7, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 246.64, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 359.13, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 338.8, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 397.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 262.0, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 246.64, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "EPINEPHRINE 0.3 MG/0.3ML IJ SOAJ", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00093598627", "type": "NDC" } ], "standard_charges": [ { "minimum": 133.99, "maximum": 1158.0, "gross_charge": 475.49, "discounted_cash": 261.52, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 275.78, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 259.62, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 412.73, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 138.37, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 228.24, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 284.82, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 284.34, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 446.96, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 418.43, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 133.99, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 404.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 356.62, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 167.52, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 323.33, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 446.96, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 372.31, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 259.62, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 378.01, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 356.62, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 418.43, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 275.78, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 259.62, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "EPINEPHRINE 1MG/10ML INJ SOSY (MULTI-GPI)", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "76329331801", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "EPINEPHRINE HCL (NASAL) 0.1 % NA SOLN", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "54288012301", "type": "NDC" } ], "standard_charges": [ { "minimum": 41.48, "maximum": 138.35, "gross_charge": 147.18, "discounted_cash": 80.95, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 85.36, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 80.36, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 117.74, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 124.66, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.83, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 70.65, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.16, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.01, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 138.35, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 129.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.48, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 125.1, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 110.39, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 51.85, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 100.08, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 138.35, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 115.24, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 80.36, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 117.01, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 110.39, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 129.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 85.36, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 80.36, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "EPINEPHRINE HCL 1 MG/ML INJ (MULTI GPI)", "drug_information": { "unit": "30.000000", "type": "UN" }, "code_information": [ { "code": "76329906000_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 201.0, "maximum": 670.47, "gross_charge": 713.27, "discounted_cash": 392.3, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 413.7, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 389.45, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 570.62, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 604.14, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 207.56, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 342.37, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 427.25, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 426.54, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 670.47, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 627.68, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 201.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 606.28, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 534.95, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 251.29, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 485.02, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 670.47, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 558.49, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 389.45, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 567.05, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 534.95, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 627.68, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 413.7, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 389.45, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "EPINEPHRINE HCL 1 MG/ML SOLN 1 ML VIAL (BULK CHARGE)", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "54288010310_4", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "EPINEPHRINE HCL 1 MG/ML SOLN 1 ML VIAL (BULK CHARGE)|DISCARDED DRUG NOT ADMINISTERED", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "54288010310", "type": "NDC" } ], "standard_charges": [ { "minimum": 5.58, "maximum": 18.62, "gross_charge": 19.81, "discounted_cash": 10.9, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.49, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.82, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.85, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.78, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.76, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.51, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.87, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.85, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.62, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.43, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.58, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.84, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.86, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.98, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.47, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.62, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.51, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.82, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.75, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.86, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.43, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.49, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.82, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "EPINEPHRINE HCL 1 MG/ML SOLN 30ML VIAL (BULK CHARGE)", "drug_information": { "unit": "30.000000", "type": "UN" }, "code_information": [ { "code": "76329906000_3", "type": "NDC" } ], "standard_charges": [ { "minimum": 201.0, "maximum": 670.47, "gross_charge": 713.27, "discounted_cash": 392.3, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 413.7, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 389.45, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 570.62, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 604.14, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 207.56, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 342.37, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 427.25, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 426.54, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 670.47, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 627.68, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 201.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 606.28, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 534.95, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 251.29, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 485.02, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 670.47, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 558.49, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 389.45, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 567.05, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 534.95, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 627.68, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 413.7, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 389.45, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "EPINEPHRINE PF 1 MG/ML IJ SOLN", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "54288010310_5", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "EPINEPHRINE PF 1 MG/ML IJ SOLN|DISCARDED DRUG NOT ADMINISTERED", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "54288010310_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 5.58, "maximum": 18.62, "gross_charge": 19.81, "discounted_cash": 10.9, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.49, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.82, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.85, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.78, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.76, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.51, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.87, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.85, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.62, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.43, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.58, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.84, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.86, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.98, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.47, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.62, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.51, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.82, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.75, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.86, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.43, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.49, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.82, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "EPINEPHRINE PF 10 MCG/ML 5ML SYRINGE", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "61553036333", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Episiotomy or vaginal repair", "code_information": [ { "code": "59300", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2343.63, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1736.02, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 7010.89, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 12732.38, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2343.63, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 12732.38, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "EPLERENONE 25 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687045121", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.59, "maximum": 5.3, "gross_charge": 5.64, "discounted_cash": 3.1, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.27, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.08, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.51, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.78, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.71, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.38, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.37, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.3, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.96, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.59, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.79, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.23, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.99, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.84, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.3, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.42, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.08, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.48, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.23, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.96, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.27, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.08, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "EPLERENONE 50 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "16729029410", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "EPOETIN ALFA 10000 UNIT/ML IJ SOLN", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "59676031001", "type": "NDC" } ], "standard_charges": [ { "minimum": 138.07, "maximum": 460.56, "gross_charge": 489.96, "discounted_cash": 269.48, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 284.18, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 267.52, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 391.97, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 415.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 142.58, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 235.18, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 293.49, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 293.0, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 460.56, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 431.16, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 138.07, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 416.47, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 367.47, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 172.61, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 333.17, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 460.56, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 383.64, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 267.52, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 389.52, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 367.47, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 431.16, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 284.18, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 267.52, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "EPOETIN ALFA 2000 UNIT/ML IJ SOLN", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "59676030201", "type": "NDC" } ], "standard_charges": [ { "minimum": 43.4, "maximum": 144.77, "gross_charge": 154.01, "discounted_cash": 84.71, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 89.33, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 84.09, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 123.21, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 130.45, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 44.82, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 73.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 92.25, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 92.1, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 144.77, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 135.53, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.4, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 130.91, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 115.51, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.26, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 104.73, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 144.77, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 120.59, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 84.09, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 122.44, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 115.51, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 135.53, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 89.33, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 84.09, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "EPOETIN ALFA 20000 UNIT/ML IJ SOLN", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "59676032004", "type": "NDC" } ], "standard_charges": [ { "minimum": 4.11, "maximum": 1052.7, "gross_charge": 1119.89, "discounted_cash": 615.94, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 649.54, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.11, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 895.91, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 948.55, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 325.89, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 537.55, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 670.81, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 669.69, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1052.7, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 985.5, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 315.59, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 951.91, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 839.92, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 394.54, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 761.53, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1052.7, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 876.87, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.55, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 890.31, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 839.92, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 985.5, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 649.54, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.11, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "EPOETIN ALFA 3000 UNIT/ML IJ SOLN", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "59676030301", "type": "NDC" } ], "standard_charges": [ { "minimum": 65.09, "maximum": 217.13, "gross_charge": 230.99, "discounted_cash": 127.04, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 133.97, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 126.12, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 184.79, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 195.65, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 67.22, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 110.88, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 138.36, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 138.13, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 217.13, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 203.27, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.09, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 196.34, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 173.24, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 81.38, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 157.07, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 217.13, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 180.87, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 126.12, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 183.64, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 173.24, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 203.27, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 133.97, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 126.12, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "EPOETIN ALFA 4000 UNIT/ML IJ SOLN", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "59676030401", "type": "NDC" } ], "standard_charges": [ { "minimum": 101.25, "maximum": 337.74, "gross_charge": 359.3, "discounted_cash": 197.62, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 208.39, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 196.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 287.44, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 304.33, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 104.56, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 172.46, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 215.22, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 214.86, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 337.74, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 316.18, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 101.25, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 305.41, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 269.48, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 126.58, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 244.32, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 337.74, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 281.33, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 196.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 285.64, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 269.48, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 316.18, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 208.39, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 196.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "EPOETIN ALFA 40000 UNIT/ML IJ SOLN", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "59676034001", "type": "NDC" } ], "standard_charges": [ { "minimum": 631.17, "maximum": 2105.38, "gross_charge": 2239.77, "discounted_cash": 1231.87, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1299.07, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1222.91, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": 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"standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 228.79, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 150.79, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.16, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "EPOETIN ALFA-EPBX 2000 UNIT/ML IJ SOLN", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00069130510", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.41, "maximum": 40.73, "gross_charge": 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ALFA-EPBX 3000 UNIT/ML IJ SOLN", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00069130610", "type": "NDC" } ], "standard_charges": [ { "minimum": 4.16, "maximum": 61.1, "gross_charge": 65.0, "discounted_cash": 35.75, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.7, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.16, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", 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"standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.9, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 44.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.1, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.9, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.62, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 51.68, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 48.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 57.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.7, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.16, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "EPOETIN ALFA-EPBX 4000 UNIT/ML IJ SOLN", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00069130710", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.41, "maximum": 81.46, "gross_charge": 86.66, "discounted_cash": 47.66, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.26, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.41, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 69.33, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 73.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.22, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 51.91, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 51.82, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 81.46, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 76.26, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.42, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 73.66, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.53, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 58.93, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 81.46, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 67.85, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 68.89, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 76.26, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.26, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.41, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "EPOETIN ALFA-EPBX 40000 UNIT/ML IJ SOLN", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00069130904", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.41, "maximum": 1303.41, "gross_charge": 1386.61, "discounted_cash": 762.64, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 804.23, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.41, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1109.29, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1174.46, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 403.5, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 665.57, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 830.58, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 829.19, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1303.41, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1220.22, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 390.75, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1178.62, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1039.96, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 488.5, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 942.89, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1303.41, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1085.72, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1102.35, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1039.96, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1220.22, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 804.23, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.41, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "EPOPROSTENOL SODIUM 0.5 MG IV SOLR (FLOLAN)", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "00173051700", "type": "NDC" } ], "standard_charges": [ { "minimum": 16.46, "maximum": 54.9, "gross_charge": 58.4, "discounted_cash": 32.12, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.87, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.89, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.72, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.46, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.99, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.03, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.98, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.9, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 51.39, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.46, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.64, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.8, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.57, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.71, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.9, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.73, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.89, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.43, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.8, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 51.39, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.87, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.89, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "EPOPROSTENOL SODIUM 0.5 MG IV SOLR (VELETRI)", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "66215040301", "type": "NDC" } ], "standard_charges": [ { "minimum": 20.63, "maximum": 68.81, "gross_charge": 73.2, "discounted_cash": 40.26, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.46, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.97, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 58.56, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 62.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.3, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.14, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.85, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.77, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 68.81, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 64.42, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.63, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 62.22, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.9, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.79, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.78, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 68.81, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 57.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.97, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 58.19, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.9, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 64.42, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.46, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.97, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "EPOPROSTENOL SODIUM 1.5 MG IV SOLR (FLOLAN)", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "00173051900", "type": "NDC" } ], "standard_charges": [ { "minimum": 47.71, "maximum": 159.13, "gross_charge": 169.29, "discounted_cash": 93.11, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 98.19, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 92.43, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 135.43, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 143.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.26, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 81.26, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 101.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 101.24, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 159.13, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 148.98, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.71, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 143.9, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 126.97, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.64, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 115.12, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 159.13, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 132.55, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 92.43, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 134.59, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 126.97, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 148.98, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 98.19, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 92.43, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "EPOPROSTENOL SODIUM 1.5 MG IV SOLR (VELETRI)", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "62756006040", "type": "NDC" } ], "standard_charges": [ { "minimum": 25.31, "maximum": 84.44, "gross_charge": 89.83, "discounted_cash": 49.41, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.1, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.05, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 71.86, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 76.09, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.14, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.12, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 53.81, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 53.72, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 84.44, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 79.05, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.31, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 76.36, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 67.37, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.65, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.08, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 84.44, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 70.34, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.05, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 71.41, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 67.37, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 79.05, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.1, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.05, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "EPTIFIBATIDE 20 MG/10ML IV SOLN", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "70436002680", "type": "NDC" } ], "standard_charges": [ { "minimum": 14.7, "maximum": 49.02, "gross_charge": 52.15, "discounted_cash": 28.68, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.25, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.47, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.72, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 44.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.18, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.03, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.24, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.19, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.02, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.89, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.7, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 44.33, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.11, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.37, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.46, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.02, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.83, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.47, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.46, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.11, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.89, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.25, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.47, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "EPTIFIBATIDE 200 MG/100ML IV SOLN", "drug_information": { "unit": "100.000000", "type": "UN" }, "code_information": [ { "code": "67457063010", "type": "NDC" } ], "standard_charges": [ { "minimum": 167.04, "maximum": 557.19, "gross_charge": 592.76, "discounted_cash": 326.02, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 343.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 323.65, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 474.21, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 502.07, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 172.49, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 284.52, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 355.06, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 354.47, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 557.19, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 521.63, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 167.04, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 503.85, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 444.57, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 208.83, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 403.08, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 557.19, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 464.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 323.65, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 471.24, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 444.57, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 521.63, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 343.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 323.65, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "EPTINEZUMAB-JJMR 100 MG/ML IV SOLN", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "67386013051", "type": "NDC" } ], "standard_charges": [ { "minimum": 1545.25, "maximum": 5154.48, "gross_charge": 5483.49, "discounted_cash": 3015.92, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3180.42, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2993.99, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4386.79, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4644.52, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1595.7, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2632.08, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3284.61, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 3279.13, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5154.48, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4825.47, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1545.25, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4660.97, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4112.62, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1931.83, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3728.77, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5154.48, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4293.57, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2993.99, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4359.37, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4112.62, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4825.47, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3180.42, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2993.99, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "EQ SUNSCREEN SPORT EX LOTN", "drug_information": { "unit": "236.000000", "type": "UN" }, "code_information": [ { "code": "79656004971", "type": "NDC" } ], "standard_charges": [ { "minimum": 5.09, "maximum": 16.97, "gross_charge": 18.05, "discounted_cash": 9.93, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.47, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.86, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.44, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.29, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.25, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.66, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.81, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.79, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.97, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.88, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.09, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.34, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.54, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.36, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.27, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.97, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.86, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.35, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.54, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.88, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.47, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.86, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ERAVACYCLINE DIHYDROCHLORIDE 100 MG IV SOLR", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "71773010012", "type": "NDC" } ], "standard_charges": [ { "minimum": 108.49, "maximum": 361.89, "gross_charge": 384.99, "discounted_cash": 211.74, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 223.29, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 210.2, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 307.99, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 326.09, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 112.03, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 184.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 230.61, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 230.22, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 361.89, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 338.79, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 108.49, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 327.24, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 288.74, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 135.63, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 261.79, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 361.89, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 301.45, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 210.2, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 306.07, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 288.74, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 338.79, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 223.29, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 210.2, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ERAVACYCLINE DIHYDROCHLORIDE 50 MG IV SOLR", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "71773005012", "type": "NDC" } ], "standard_charges": [ { "minimum": 51.99, "maximum": 173.42, "gross_charge": 184.49, "discounted_cash": 101.47, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 107.0, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 100.73, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 147.59, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 156.26, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 53.69, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.56, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 110.51, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 110.33, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 173.42, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 162.35, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 51.99, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 156.82, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 138.37, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.0, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 125.45, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 173.42, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 144.46, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 100.73, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 146.67, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 138.37, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 162.35, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 107.0, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 100.73, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Ercp duct stent placement", "code_information": [ { "code": "43274", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4387.82, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3250.23, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 9926.91, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 19989.55, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4387.82, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 19989.55, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Ercp ea duct/ampulla dilate", "code_information": [ { "code": "43277", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2804.32, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2077.27, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 7595.42, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 13782.01, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2804.32, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 13782.01, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Ercp lesion ablate w/dilate", "code_information": [ { "code": "43278", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2804.32, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2077.27, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 6094.7, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 12477.94, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2804.32, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 12477.94, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Ercp lithotripsy calculi", "code_information": [ { "code": "43265", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4387.82, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3250.23, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 15129.01, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 27451.82, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4387.82, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 27451.82, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Ercp remove duct calculi", "code_information": [ { "code": "43264", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2804.32, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2077.27, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 9325.62, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 16921.51, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2804.32, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 16921.51, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Ercp remove forgn body duct", "code_information": [ { "code": "43275", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1398.27, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1035.76, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 5585.9, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 11419.71, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1398.27, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 11419.71, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Ercp stent exchange w/dilate", "code_information": [ { "code": "43276", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4387.82, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3250.23, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 9532.19, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 17296.34, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4387.82, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 17296.34, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Ercp w/specimen collection", "code_information": [ { "code": "43260", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2804.32, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2077.27, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 7961.77, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 14446.76, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2804.32, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 14446.76, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ERGOCALCIFEROL 200 MCG (8000 UNITS)/ML PO SOLN", "drug_information": { "unit": "60.000000", "type": "UN" }, "code_information": [ { "code": "69367028302", "type": "NDC" } ], "standard_charges": [ { "minimum": 16.17, "maximum": 53.94, "gross_charge": 57.38, "discounted_cash": 31.56, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.28, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.33, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.9, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 48.6, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.7, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.54, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.37, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.31, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 53.94, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.49, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.17, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 48.77, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.04, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.21, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.02, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 53.94, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 44.93, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.33, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.62, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.04, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.49, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.28, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.33, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ERIBULIN CHEMO SYRINGE", "drug_information": { "unit": "2.000000", "type": "UN" }, "code_information": [ { "code": "62856038901_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 74.14, "maximum": 5367.4, "gross_charge": 5710.0, "discounted_cash": 3140.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3311.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.14, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4568.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4836.37, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1661.61, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2740.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3420.29, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 3414.58, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5367.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5024.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1609.08, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4853.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4282.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2011.63, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3882.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5367.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4470.93, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 100.09, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4539.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4282.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5024.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3311.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.14, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "ERIBULIN CHEMO SYRINGE|DISCARDED DRUG NOT ADMINISTERED", "drug_information": { "unit": "2.000000", "type": "UN" }, "code_information": [ { "code": "62856038901", "type": "NDC" } ], "standard_charges": [ { "minimum": 74.14, "maximum": 5301.6, "gross_charge": 5640.0, "discounted_cash": 3102.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3271.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.14, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4512.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4777.08, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1641.24, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2707.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3378.36, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 3372.72, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5301.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4963.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1589.35, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4794.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4230.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1986.97, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3835.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5301.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4416.12, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 100.09, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4483.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4230.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4963.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3271.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.14, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "ERLOTINIB HCL 100 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "50242006301", "type": "NDC" } ], "standard_charges": [ { "minimum": 245.66, "maximum": 819.44, "gross_charge": 871.74, "discounted_cash": 479.46, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 505.61, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 475.97, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 697.39, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 738.36, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 253.68, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 418.44, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 522.17, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 521.3, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 819.44, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 767.13, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 245.66, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 740.98, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 653.81, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 307.11, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 592.78, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 819.44, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 682.57, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 475.97, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 693.03, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 653.81, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 767.13, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 505.61, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 475.97, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ERLOTINIB HCL 150 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68382091506", "type": "NDC" } ], "standard_charges": [ { "minimum": 5.17, "maximum": 17.24, "gross_charge": 18.34, "discounted_cash": 10.09, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.01, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.67, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.53, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.34, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.99, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.97, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.24, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.14, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.17, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.59, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.76, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.46, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.47, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.24, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.36, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.01, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.58, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.76, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.14, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.01, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ERTAPENEM 1 G (MINIBAG-IVAS)", "drug_information": { "unit": "50.000000", "type": "UN" }, "code_information": [ { "code": "4202322101", "type": "NDC" } ], "standard_charges": [ { "minimum": 15.63, "maximum": 52.15, "gross_charge": 55.48, "discounted_cash": 30.51, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.18, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.29, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 44.38, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.99, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.14, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.63, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.23, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.18, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.15, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 48.82, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.63, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.16, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.61, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.55, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.73, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.15, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.44, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.29, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 44.11, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.61, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 48.82, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.18, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.29, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ERTAPENEM SODIUM 1 G IJ SOLR", "drug_information": { "unit": "3.570000", "type": "UN" }, "code_information": [ { "code": "00143939810", "type": "NDC" } ], "standard_charges": [ { "minimum": 15.63, "maximum": 52.15, "gross_charge": 55.48, "discounted_cash": 30.51, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.18, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.29, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 44.38, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.99, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.14, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.63, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.23, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.18, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.15, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 48.82, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.63, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.16, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.61, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.55, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.73, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.15, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.44, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.29, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 44.11, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.61, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 48.82, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.18, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.29, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ERTAPENEM SODIUM 1 G IV", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "00143939810_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 15.63, "maximum": 52.15, "gross_charge": 55.48, "discounted_cash": 30.51, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.18, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.29, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 44.38, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.99, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.14, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.63, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.23, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.18, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.15, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 48.82, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.63, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.16, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.61, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.55, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.73, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.15, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.44, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.29, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 44.11, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.61, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 48.82, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.18, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.29, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ERTAPENEM SODIUM 1 G IV SOLR", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "00143939810_3", "type": "NDC" } ], "standard_charges": [ { "minimum": 15.63, "maximum": 52.15, "gross_charge": 55.48, "discounted_cash": 30.51, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.18, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.29, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 44.38, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.99, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.14, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.63, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.23, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.18, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.15, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 48.82, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.63, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.16, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.61, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.55, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.73, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.15, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.44, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.29, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 44.11, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.61, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 48.82, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.18, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.29, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ERYTHROMYCIN 2 % EX GEL", "drug_information": { "unit": "30.000000", "type": "GR" }, "code_information": [ { "code": "45802096694", "type": "NDC" } ], "standard_charges": [ { "minimum": 26.52, "maximum": 88.45, "gross_charge": 94.1, "discounted_cash": 51.76, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.58, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 51.38, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.28, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 79.7, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.38, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.17, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 56.37, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 56.27, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.45, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.81, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.52, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 79.99, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 70.58, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.15, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.99, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.45, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 73.68, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 51.38, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.81, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 70.58, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.81, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.58, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 51.38, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ERYTHROMYCIN 2 % EX SOLN", "drug_information": { "unit": "60.000000", "type": "UN" }, "code_information": [ { "code": "45802003846", "type": "NDC" } ], "standard_charges": [ { "minimum": 9.41, "maximum": 31.4, "gross_charge": 33.4, "discounted_cash": 18.37, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.37, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.24, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.72, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.29, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.72, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.03, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.01, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.97, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.39, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.41, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.05, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.77, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.71, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.15, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.24, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.55, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.05, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.39, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.37, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.24, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ERYTHROMYCIN 5 MG/GM OP OINT", "drug_information": { "unit": "1.000000", "type": "GR" }, "code_information": [ { "code": "24208091019", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ERYTHROMYCIN BASE 250 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "1366860601", "type": "NDC" } ], "standard_charges": [ { "minimum": 5.19, "maximum": 17.32, "gross_charge": 18.43, "discounted_cash": 10.14, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.69, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.74, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.61, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.36, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.85, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.04, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.02, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.32, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.22, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.19, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.67, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.82, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.49, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.53, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.32, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.43, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.65, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.82, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.22, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.69, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ERYTHROMYCIN BASE 250 MG PO TBEC", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "R5253618003", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.45, "maximum": 8.16, "gross_charge": 8.68, "discounted_cash": 4.77, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.03, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.74, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.94, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.35, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.53, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.17, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.2, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.19, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.16, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.64, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.45, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.38, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.51, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.06, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.9, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.16, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.8, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.74, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.9, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.51, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.64, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.03, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.74, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ERYTHROMYCIN ETHYLSUCCINATE 200 MG/5ML PO SUSR", "drug_information": { "unit": "100.000000", "type": "UN" }, "code_information": [ { "code": "62559063001", "type": "NDC" } ], "standard_charges": [ { "minimum": 85.32, "maximum": 284.61, "gross_charge": 302.78, "discounted_cash": 166.53, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 175.61, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 165.32, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 242.22, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 256.45, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.11, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 145.33, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 181.37, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 181.06, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 284.61, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 266.45, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 85.32, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 257.36, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 227.09, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 106.67, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 205.89, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 284.61, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 237.08, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 165.32, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 240.71, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 227.09, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 266.45, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 175.61, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 165.32, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ERYTHROMYCIN ETHYLSUCCINATE 400 MG/5ML PO SUSR", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "69238150402", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.84, "maximum": 39.5, "gross_charge": 42.02, "discounted_cash": 23.11, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.37, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.94, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.62, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.59, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.23, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.17, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.17, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.13, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.5, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.98, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.84, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.72, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.52, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.8, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.57, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.5, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.9, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.94, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.41, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.52, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.98, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.37, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.94, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ERYTHROMYCIN LACTOBIONATE 500 MG IV SOLR", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "00409648201", "type": "NDC" } ], "standard_charges": [ { "minimum": 43.95, "maximum": 146.6, "gross_charge": 155.96, "discounted_cash": 85.78, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 90.46, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 85.15, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 124.77, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 132.1, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.38, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.86, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.42, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.26, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 146.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 137.24, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.95, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 132.57, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 116.97, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.94, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 106.05, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 146.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 122.12, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 85.15, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 123.99, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 116.97, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 137.24, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 90.46, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 85.15, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ESCITALOPRAM OXALATE 10 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00904642661", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ESCITALOPRAM OXALATE 20 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00904642761", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ESCITALOPRAM OXALATE 5 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "R4354728010", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ESCITALOPRAM OXALATE 5 MG/5ML PO SOLN", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "65162070588", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Esd endoscopy or colonoscopy", "code_information": [ { "code": "C9779", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2804.32, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2077.27, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 6674.88, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 12111.68, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2804.32, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 12111.68, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ESLICARBAZEPINE ACETATE 200 MG PO TABS", "drug_information": { "unit": "2.000000", "type": "UN" }, "code_information": [ { "code": "63402020230", "type": "NDC" } ], "standard_charges": [ { "minimum": 53.92, "maximum": 179.87, "gross_charge": 191.35, "discounted_cash": 105.24, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 110.98, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 104.48, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 153.08, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 162.07, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.68, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 91.85, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 114.62, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 114.43, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 179.87, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 168.39, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 53.92, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 162.65, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 143.51, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 67.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 130.12, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 179.87, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 149.83, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 104.48, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 152.12, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 143.51, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 168.39, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 110.98, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 104.48, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ESLICARBAZEPINE ACETATE 400 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "63402020430", "type": "NDC" } ], "standard_charges": [ { "minimum": 26.96, "maximum": 89.94, "gross_charge": 95.68, "discounted_cash": 52.62, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.49, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.24, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 76.54, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 81.04, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.84, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.93, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 57.31, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 57.22, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 89.94, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 84.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.96, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 81.33, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 71.76, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.71, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.06, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 89.94, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.92, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.24, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 76.07, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 71.76, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 84.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.49, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.24, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ESLICARBAZEPINE ACETATE 600 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "63402020660", "type": "NDC" } ], "standard_charges": [ { "minimum": 26.96, "maximum": 89.94, "gross_charge": 95.68, "discounted_cash": 52.62, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.49, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.24, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 76.54, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 81.04, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.84, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.93, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 57.31, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 57.22, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 89.94, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 84.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.96, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 81.33, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 71.76, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.71, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.06, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 89.94, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.92, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.24, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 76.07, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 71.76, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 84.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.49, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.24, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ESLICARBAZEPINE ACETATE 800 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "63402020830", "type": "NDC" } ], "standard_charges": [ { "minimum": 26.96, "maximum": 89.94, "gross_charge": 95.68, "discounted_cash": 52.62, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.49, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.24, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 76.54, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 81.04, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.84, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.93, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 57.31, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 57.22, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 89.94, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 84.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.96, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 81.33, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 71.76, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.71, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.06, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 89.94, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.92, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.24, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 76.07, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 71.76, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 84.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.49, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.24, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ESMOLOL 10 MG/ML SYR FROM NS RTU (PEDS)", "drug_information": { "unit": "250.000000", "type": "UN" }, "code_information": [ { "code": "44567045010", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ESMOLOL 2500 MG/250 ML RTU", "drug_information": { "unit": "250.000000", "type": "UN" }, "code_information": [ { "code": "25021030884", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ESMOLOL HCL 100 MG/10ML IV SOLN", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "55150019410_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ESMOLOL HCL 100 MG/10ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "55150019410", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.81, "maximum": 9.36, "gross_charge": 9.96, "discounted_cash": 5.48, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.78, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.44, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.97, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.44, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.9, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.78, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.97, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.36, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.76, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.81, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.47, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.47, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.51, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.77, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.36, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.8, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.44, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.92, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.47, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.76, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.78, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.44, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ESMOLOL HCL 2500 MG/250ML IV SOLN", "drug_information": { "unit": "250.000000", "type": "UN" }, "code_information": [ { "code": "44567081110_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ESMOLOL HCL 2500 MG/250ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED", "drug_information": { "unit": "250.000000", "type": "UN" }, "code_information": [ { "code": "44567081110", "type": "NDC" } ], "standard_charges": [ { "minimum": 25.73, "maximum": 85.82, "gross_charge": 91.3, "discounted_cash": 50.22, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.95, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.85, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 73.04, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 77.33, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.57, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.82, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.69, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.6, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 85.82, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 80.34, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.73, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 77.61, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 68.48, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.16, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 62.08, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 85.82, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 71.49, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.85, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 72.58, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 68.48, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 80.34, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.95, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.85, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ESOMEPRAZOLE MAGNESIUM 20 MG PO CPDR", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00186502031", "type": "NDC" } ], "standard_charges": [ { "minimum": 5.85, "maximum": 19.51, "gross_charge": 20.76, "discounted_cash": 11.42, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.04, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.33, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.61, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.58, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.04, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.96, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.44, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.41, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.51, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.27, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.85, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.65, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.57, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.31, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.12, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.51, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.26, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.33, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.5, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.57, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.27, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.04, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.33, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ESOMEPRAZOLE MAGNESIUM 40 MG PO CPDR", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "65862078430", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Esoph balloon distension tst", "code_information": [ { "code": "91040", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 391.11, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 289.71, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 4553.5, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 8262.4, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 391.11, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 8262.4, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Esoph egd dilation <30 mm", "code_information": [ { "code": "43249", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1398.27, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1035.76, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 4278.09, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 7762.66, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1398.27, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 7762.66, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Esoph endoscopy dilation", "code_information": [ { "code": "43226", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1398.27, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1035.76, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 8776.33, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 15924.79, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1398.27, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 15924.79, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Esoph imped funct test > 1hr", "code_information": [ { "code": "91038", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 391.11, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 289.71, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 4334.85, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 7865.65, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 391.11, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 7865.65, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Esoph imped function test", "code_information": [ { "code": "91037", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 229.53, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 170.02, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 3967.98, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 7199.96, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 229.53, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 7199.96, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Esoph scope w/submucous inj", "code_information": [ { "code": "43201", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1398.27, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1035.76, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 4463.87, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 8099.78, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1398.27, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 8099.78, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Esophagosc dilate balloon 30", "code_information": [ { "code": "43214", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1398.27, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1035.76, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 10184.82, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 18480.53, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1398.27, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 18480.53, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Esophagoscop stent placement", "code_information": [ { "code": "43212", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4387.82, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3250.23, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 8789.16, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 15948.07, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4387.82, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 15948.07, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Esophagoscop ultrasound exam", "code_information": [ { "code": "43231", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1398.27, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1035.76, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 2842.08, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 5157.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1398.27, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 5157.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Esophagoscopy balloon <30mm", "code_information": [ { "code": "43220", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1398.27, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1035.76, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 11639.78, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 21120.57, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1398.27, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 21120.57, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Esophagoscopy flex biopsy", "code_information": [ { "code": "43202", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1398.27, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1035.76, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 10738.55, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 19485.28, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1398.27, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 19485.28, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Esophagoscopy flexible brush", "code_information": [ { "code": "43200", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 691.08, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 511.91, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 10760.67, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 19525.41, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 691.08, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 19525.41, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Esophagoscopy lesion ablate", "code_information": [ { "code": "43229", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2804.32, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2077.27, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 7818.35, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 14186.53, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2804.32, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 14186.53, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Esophagoscopy retro balloon", "code_information": [ { "code": "43213", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1398.27, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1035.76, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 12873.06, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 23358.4, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1398.27, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 23358.4, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Esophagoscopy rigid balloon", "code_information": [ { "code": "43195", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2804.32, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2077.27, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 10699.23, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 19413.92, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2804.32, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 19413.92, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Esophagoscopy rigid trnso", "code_information": [ { "code": "43180", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4360.43, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3229.95, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 14418.08, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 26161.84, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4360.43, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 26161.84, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Esophagoscopy rigid trnso dx", "code_information": [ { "code": "43191", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1398.27, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1035.76, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 10366.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 18809.28, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1398.27, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 18809.28, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Esophagoscp guide wire dilat", "code_information": [ { "code": "43196", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1398.27, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1035.76, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 10501.36, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 19054.91, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1398.27, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 19054.91, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Esophagoscp rig trnso biopsy", "code_information": [ { "code": "43193", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1398.27, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1035.76, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 11150.04, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 20231.94, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1398.27, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 20231.94, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Esophagoscp rig trnso inject", "code_information": [ { "code": "43192", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1398.27, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1035.76, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 12727.9, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 23164.05, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1398.27, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 23164.05, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Esophagoscp rig trnso rem fb", "code_information": [ { "code": "43194", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1398.27, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1035.76, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 6514.14, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 11820.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1398.27, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 11820.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Esophagus motility study", "code_information": [ { "code": "91010", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 391.11, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 289.71, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 3947.28, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 7162.4, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 391.11, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 7162.4, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "EST ESTROGENS-METHYLTEST 0.625-1.25 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "62559015001", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ESTERIFIED ESTROGENS 0.3 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "61570007201", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.19, "maximum": 3.99, "gross_charge": 4.24, "discounted_cash": 2.33, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.46, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.59, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.23, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.04, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.54, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.54, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.99, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.73, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.19, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.6, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.49, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.88, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": 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total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.73, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.46, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ESTERIFIED ESTROGENS 0.625 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "61570007301", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.7, "maximum": 5.67, "gross_charge": 6.03, "discounted_cash": 3.32, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.5, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.29, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.82, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.11, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.75, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.89, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.61, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.61, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.67, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.31, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.7, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.13, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.52, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.12, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.1, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.67, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.72, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.29, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.79, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.52, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.31, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.5, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.29, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ESTERIFIED ESTROGENS 1.25 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "61570007401", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.37, "maximum": 7.9, "gross_charge": 8.4, "discounted_cash": 4.62, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.87, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.59, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.72, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.11, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.44, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.03, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.03, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.02, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.9, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.39, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.37, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.14, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.3, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.96, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.71, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.9, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.58, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.59, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.68, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.3, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.39, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.87, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.59, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ESTRADIOL 0.025 MG/24HR TD PTTW", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00078036542", "type": "NDC" } ], "standard_charges": [ { "minimum": 12.23, "maximum": 40.81, "gross_charge": 43.41, "discounted_cash": 23.88, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.18, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.7, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.73, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.77, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.63, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.84, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.0, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.81, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.23, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.9, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.56, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.29, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.52, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.81, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.99, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.7, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.51, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.56, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.18, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.7, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ESTRADIOL 0.0375 MG/24HR TD PTTW", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00078034342", "type": "NDC" } ], "standard_charges": [ { "minimum": 12.24, "maximum": 40.81, "gross_charge": 43.42, "discounted_cash": 23.88, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.18, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.71, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.74, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.78, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.84, "standard_charge_percentage": 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"additional_payer_notes": "N/A", "standard_charge_dollar": 34.34, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.4, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.02, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.06, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.59, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ESTRADIOL 0.075 MG/24HR TD PTWK", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00378335199", "type": "NDC" } ], "standard_charges": [ { "minimum": 6.9, "maximum": 23.03, "gross_charge": 24.5, "discounted_cash": 13.48, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.21, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.38, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.6, "standard_charge_percentage": 80.0, "methodology": 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60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.03, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.56, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.9, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.83, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.38, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.63, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.66, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.03, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.18, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { 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"percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.38, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ESTRADIOL 0.1 MG/24HR TD PTWK", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00378335299", "type": "NDC" } ], "standard_charges": [ { "minimum": 9.57, "maximum": 31.92, "gross_charge": 33.96, "discounted_cash": 18.68, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.7, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.54, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.17, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.76, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.88, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.3, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.34, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.31, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.92, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.88, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.57, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.87, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.47, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.96, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.09, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.92, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.59, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.54, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.47, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.88, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.7, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.54, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ESTRADIOL 0.1 MG/GM VA CREA", "drug_information": { "unit": "43.000000", "type": "GR" }, "code_information": [ { "code": "00430375414", "type": "NDC" } ], "standard_charges": [ { "minimum": 439.99, "maximum": 1467.67, "gross_charge": 1561.35, "discounted_cash": 858.74, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 905.58, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 852.5, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1249.08, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1322.46, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 454.35, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 749.45, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 935.25, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 933.69, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1467.67, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1373.99, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 439.99, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1327.15, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1171.01, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 550.06, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1061.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1467.67, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1222.54, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 852.5, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1241.27, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1171.01, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1373.99, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 905.58, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 852.5, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ESTRADIOL 0.5 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "70954056410", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ESTRADIOL 1 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "2465870301", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ESTRADIOL 10 MCG VA TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00169517603", "type": "NDC" } ], "standard_charges": [ { "minimum": 13.57, "maximum": 45.27, "gross_charge": 48.16, "discounted_cash": 26.49, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.93, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.3, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.53, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.79, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.12, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.85, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.8, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.27, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.38, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.57, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.94, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.12, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.97, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.75, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.27, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.71, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.3, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.29, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.12, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.38, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.93, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.3, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ESTRADIOL 2 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "42806008901", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ESTRADIOL CYPIONATE 5 MG/ML IM OIL", "drug_information": { "unit": "0.200000", "type": "UN" }, "code_information": [ { "code": "00009027101", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ESTRADIOL VALERATE 10 MG/ML IM OIL", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "42023011001", "type": "NDC" } ], "standard_charges": [ { "minimum": 16.94, "maximum": 56.5, "gross_charge": 60.11, "discounted_cash": 33.06, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.86, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.82, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 48.09, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.91, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.49, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.85, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.01, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.95, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 56.5, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.9, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.94, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 51.09, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.08, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.18, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.87, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 56.5, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.07, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.82, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.79, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.08, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.9, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.86, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.82, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ESTRADIOL VALERATE 20 MG/ML IM OIL", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "00517042001", "type": "NDC" } ], "standard_charges": [ { "minimum": 74.13, "maximum": 247.29, "gross_charge": 263.07, "discounted_cash": 144.69, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 152.58, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 143.64, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 210.46, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 222.82, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 76.55, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 126.27, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 157.58, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 157.32, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 247.29, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 231.5, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 223.61, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 197.3, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 92.68, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 178.89, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 247.29, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 205.98, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 143.64, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 209.14, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 197.3, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 231.5, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 152.58, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 143.64, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ESTRADIOL-LEVONORGESTREL 0.045-0.015 MG/DAY TD PTWK", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "50419049104", "type": "NDC" } ], "standard_charges": [ { "minimum": 47.8, "maximum": 159.46, "gross_charge": 169.64, "discounted_cash": 93.3, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 98.39, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 92.62, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 135.71, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 143.69, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.37, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 81.43, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 101.61, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 101.44, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 159.46, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 149.28, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.8, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 144.19, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 127.23, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.76, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 115.36, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 159.46, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 132.83, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 92.62, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 134.86, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 127.23, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 149.28, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 98.39, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 92.62, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ESTRADIOL-NORETHINDRONE ACET 1-0.5 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00378729553", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed 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total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ESTROGENS CONJUGATED 0.3 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00046110081", "type": "NDC" } ], "standard_charges": [ { "minimum": 4.41, "maximum": 14.7, "gross_charge": 15.64, "discounted_cash": 8.6, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.07, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.54, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.51, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.25, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.55, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.51, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.37, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.35, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.7, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.76, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.41, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.29, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.73, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.51, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.64, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.7, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.25, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.54, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.43, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.73, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.76, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.07, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.54, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ESTROGENS CONJUGATED 0.45 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00046110181", "type": "NDC" } ], "standard_charges": [ { "minimum": 4.41, "maximum": 14.7, "gross_charge": 15.64, "discounted_cash": 8.6, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.07, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.54, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.51, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.25, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.55, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.51, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.37, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.35, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.7, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.76, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.41, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.29, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.73, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.51, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.64, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.7, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.25, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.54, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.43, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.73, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.76, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.07, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.54, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ESTROGENS CONJUGATED 0.625 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00046110281", "type": "NDC" } ], "standard_charges": [ { "minimum": 4.41, "maximum": 14.7, "gross_charge": 15.64, "discounted_cash": 8.6, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.07, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.54, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.51, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.25, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.55, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.51, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.37, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.35, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.7, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.76, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.41, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.29, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.73, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.51, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.64, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.7, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.25, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.54, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.43, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.73, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.76, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.07, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.54, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ESTROGENS CONJUGATED 0.625 MG/GM VA CREA", "drug_information": { "unit": "30.000000", "type": "GR" }, "code_information": [ { "code": "00046087221", "type": "NDC" } ], "standard_charges": [ { "minimum": 287.17, "maximum": 957.91, "gross_charge": 1019.05, "discounted_cash": 560.48, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 591.05, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 556.4, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 815.24, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 863.14, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 296.54, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 489.14, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 610.41, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 609.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 957.91, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 896.76, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 287.17, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 866.19, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 764.29, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 359.01, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 692.95, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 957.91, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 797.92, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 556.4, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 810.14, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 764.29, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 896.76, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 591.05, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 556.4, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ESTROGENS CONJUGATED 25 MG IJ SOLR", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "00046074905", "type": "NDC" } ], "standard_charges": [ { "minimum": 209.0, "maximum": 1253.4, "gross_charge": 1333.4, "discounted_cash": 733.37, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 773.37, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 209.0, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1066.72, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1129.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 388.02, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 640.03, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 798.71, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 797.37, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1253.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1173.39, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 375.75, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1133.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1000.05, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 469.76, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 906.71, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1253.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1044.05, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 282.15, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1060.05, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1000.05, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1173.39, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 773.37, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 209.0, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "ESZOPICLONE 1 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "3172285501", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.25, "maximum": 7.52, "gross_charge": 8.0, "discounted_cash": 4.4, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.4, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.78, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.33, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.84, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.79, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.25, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.8, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.82, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.44, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.26, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.36, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ESZOPICLONE 2 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "33342030011", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.25, "maximum": 7.52, "gross_charge": 8.0, "discounted_cash": 4.4, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.4, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.78, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.33, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.84, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.79, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.25, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.8, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.82, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.44, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.26, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.36, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ETANERCEPT 25 MG/0.5ML SC SOLN", "drug_information": { "unit": "0.500000", "type": "UN" }, "code_information": [ { "code": "58406005504", "type": "NDC" } ], "standard_charges": [ { "minimum": 431.77, "maximum": 3475.75, "gross_charge": 3697.61, "discounted_cash": 2033.69, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2144.61, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 431.77, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2958.09, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3131.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1076.0, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1774.85, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2214.87, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2211.17, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3475.75, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3253.9, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1041.99, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3142.97, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2773.21, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1302.67, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2514.37, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3475.75, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2895.23, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 582.88, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2939.6, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2773.21, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3253.9, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2144.61, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 431.77, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "ETANERCEPT 25 MG/0.5ML SC SOSY", "drug_information": { "unit": "0.500000", "type": "UN" }, "code_information": [ { "code": "58406001004", "type": "NDC" } ], "standard_charges": [ { "minimum": 431.77, "maximum": 3245.35, "gross_charge": 3452.5, "discounted_cash": 1898.88, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2002.45, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 431.77, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2762.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2924.27, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1004.68, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1657.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2068.05, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2064.6, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3245.35, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3038.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 972.91, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2934.63, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2589.38, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1216.32, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2347.7, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3245.35, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2703.31, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 582.88, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2744.74, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2589.38, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3038.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2002.45, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 431.77, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "ETANERCEPT 50 MG/ML SC SOSY", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "58406002104", "type": "NDC" } ], "standard_charges": [ { "minimum": 431.77, "maximum": 4868.02, "gross_charge": 5178.74, "discounted_cash": 2848.31, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3003.67, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 431.77, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4142.99, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4386.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1507.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2485.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3102.07, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 3096.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4868.02, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4557.29, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1459.37, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4401.93, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3884.06, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1824.47, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3521.54, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4868.02, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4054.95, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 582.88, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4117.1, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3884.06, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4557.29, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3003.67, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 431.77, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "ETELCALCETIDE HCL 2.5 MG/0.5ML IV SOLN", "drug_information": { "unit": "0.500000", "type": "UN" }, "code_information": [ { "code": "55513074010", "type": "NDC" } ], "standard_charges": [ { "minimum": 83.11, "maximum": 277.23, "gross_charge": 294.93, "discounted_cash": 162.21, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 171.06, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 161.03, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 235.94, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 249.81, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 85.82, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 141.57, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 176.66, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 176.37, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 277.23, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 259.54, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 83.11, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 250.69, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 221.2, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.9, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 200.55, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 277.23, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 230.93, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 161.03, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 234.47, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 221.2, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 259.54, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 171.06, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 161.03, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ETEPLIRSEN 100 MG/2ML IV SOLN", "drug_information": { "unit": "2.000000", "type": "UN" }, "code_information": [ { "code": "60923036302", "type": "NDC" } ], "standard_charges": [ { "minimum": 1352.64, "maximum": 4512.0, "gross_charge": 4800.0, "discounted_cash": 2640.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2784.0, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2620.8, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3840.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4065.6, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1396.8, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2304.0, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2875.2, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2870.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4512.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4224.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1352.64, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4080.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3600.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1691.04, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3264.0, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4512.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3758.4, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2620.8, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3816.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3600.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4224.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2784.0, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2620.8, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ETHACRYNATE SODIUM 50 MG IV SOLR", "drug_information": { "unit": "50.000000", "type": "UN" }, "code_information": [ { "code": "42023015701", "type": "NDC" } ], "standard_charges": [ { "minimum": 1158.0, "maximum": 5823.3, "gross_charge": 6195.0, "discounted_cash": 3407.25, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3593.1, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3382.47, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5377.26, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1802.75, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2973.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3710.81, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 3704.61, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5823.3, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5451.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1745.75, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5265.75, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4646.25, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2182.5, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4212.6, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5823.3, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4850.69, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3382.47, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4925.03, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4646.25, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5451.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3593.1, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3382.47, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ETHACRYNIC ACID 25 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00832169011", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ETHAMBUTOL HCL 100 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68180028001", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ETHAMBUTOL HCL 400 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68084028001", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ETHANOL 99 % IJ SOLN", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "54288010515", "type": "NDC" } ], "standard_charges": [ { "minimum": 837.14, "maximum": 2792.46, "gross_charge": 2970.7, "discounted_cash": 1633.89, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1723.01, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1622.0, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2578.57, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 864.47, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1425.94, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1779.45, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 1776.48, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2792.46, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2614.22, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 837.14, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2525.1, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2228.03, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1046.58, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2020.08, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2792.46, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2326.06, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1622.0, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2361.71, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2228.03, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2614.22, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1723.01, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1622.0, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ETHANOLAMINE OLEATE 5 % IV SOLN", "drug_information": { "unit": "1.500000", "type": "UN" }, "code_information": [ { "code": "67871479006", "type": "NDC" } ], "standard_charges": [ { "minimum": 268.46, "maximum": 1635.98, "gross_charge": 1740.4, "discounted_cash": 957.22, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1009.43, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 268.46, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1392.32, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1474.12, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 506.46, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 835.39, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1042.5, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 1040.76, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1635.98, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1531.55, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 490.44, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1479.34, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1305.3, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 613.14, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1183.47, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1635.98, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1362.73, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 362.42, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1383.62, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1305.3, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1531.55, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1009.43, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 268.46, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "ETHIODIZED OIL 480 MG/ML IJ OIL", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "67684190102", "type": "NDC" } ], "standard_charges": [ { "minimum": 1055.06, "maximum": 3519.36, "gross_charge": 3744.0, "discounted_cash": 2059.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2171.52, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2044.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2995.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3171.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1089.5, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1797.12, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2242.66, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2238.91, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3519.36, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3294.72, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1055.06, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3182.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2808.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1319.01, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2545.92, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3519.36, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2931.55, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2044.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2976.48, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2808.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3294.72, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2171.52, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2044.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ETHIONAMIDE 250 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00008411701", "type": "NDC" } ], "standard_charges": [ { "minimum": 3.58, "maximum": 11.93, "gross_charge": 12.69, "discounted_cash": 6.98, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.36, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.93, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.15, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.75, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.69, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.09, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.6, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.59, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.93, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.17, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.58, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.79, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.52, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.47, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.63, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.93, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.94, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.93, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.09, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.52, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.17, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.36, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.93, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ETHOSUXIMIDE 250 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "64380087806", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ETHOSUXIMIDE 250 MG/5ML PO SOLN", "drug_information": { "unit": "473.000000", "type": "UN" }, "code_information": [ { "code": "00121067016", "type": "NDC" } ], "standard_charges": [ { "minimum": 24.26, "maximum": 80.93, "gross_charge": 86.1, "discounted_cash": 47.36, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.94, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.01, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 68.88, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 72.93, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.06, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.33, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 51.57, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 51.49, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 80.93, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.77, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.26, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 73.19, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 64.58, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.33, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 58.55, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 80.93, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 67.42, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.01, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 68.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 64.58, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.77, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.94, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.01, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ETHYL CHLORIDE EX AERO", "drug_information": { "unit": "116.000000", "type": "UN" }, "code_information": [ { "code": "00386000103", "type": "NDC" } ], "standard_charges": [ { "minimum": 22.95, "maximum": 76.54, "gross_charge": 81.43, "discounted_cash": 44.79, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.23, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 44.46, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.14, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 68.97, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.7, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.09, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 48.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 48.7, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 76.54, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 71.66, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.95, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 69.22, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.07, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.69, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.37, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 76.54, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.76, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 44.46, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 64.74, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.07, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 71.66, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.23, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 44.46, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ETHYNODIOL DIAC-ETH ESTRADIOL 1-35 MG-MCG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00555906458", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ETODOLAC 500 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "51672403601", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ETOMIDATE 2 MG/ML IV SOLN", "drug_information": { "unit": "20.000000", "type": "UN" }, "code_information": [ { "code": "00143950710", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 1158.0, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.72, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ETOMIDATE 2 MG/ML IV SOLN - CODE USE PEDS", "drug_information": { "unit": "20.000000", "type": "UN" }, "code_information": [ { "code": "00143950710_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 1158.0, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.72, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ETONOGESTREL 68 MG SC IMPL", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "78206014501", "type": "NDC" } ], "standard_charges": [ { "minimum": 977.52, "maximum": 3260.71, "gross_charge": 3468.84, "discounted_cash": 1907.86, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2011.93, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1893.99, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2775.07, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2938.11, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1009.43, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1665.04, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2077.84, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2074.37, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3260.71, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3052.58, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 977.52, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2948.51, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2601.63, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1222.07, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2358.81, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3260.71, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2716.1, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1893.99, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2757.73, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2601.63, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3052.58, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2011.93, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1893.99, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ETOPOSIDE 10 MG/ML ORAL SOLUTION", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "C0703565601", "type": "NDC" } ], "standard_charges": [ { "minimum": 8.67, "maximum": 28.91, "gross_charge": 30.75, "discounted_cash": 16.91, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.84, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.79, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.6, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.05, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.95, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.76, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.42, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.91, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.06, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.67, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.14, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.06, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.83, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.91, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.91, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.08, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.79, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.06, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.06, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.84, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.79, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ETOPOSIDE 100 MG/5ML IV SOLN", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "16729011431", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ETOPOSIDE 500 MG/25ML IV SOLN", "drug_information": { "unit": "25.000000", "type": "UN" }, "code_information": [ { "code": "16729011408", "type": "NDC" } ], "standard_charges": [ { "minimum": 32.86, "maximum": 109.6, "gross_charge": 116.6, "discounted_cash": 64.13, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 67.63, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.66, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.28, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 98.76, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.93, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.97, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 69.84, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 69.73, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 109.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 102.61, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.86, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 99.11, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.08, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 79.29, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 109.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 91.3, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.66, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 92.7, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 102.61, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 67.63, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.66, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ETOPOSIDE CHEMO INFUSION (BMT)(STRAIGHT DRUG)", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "16729011431_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ETOPOSIDE PHOSPHATE 100 MG IV SOLR", "drug_information": { "unit": "100.000000", "type": "ME" }, "code_information": [ { "code": "61269041020", "type": "NDC" } ], "standard_charges": [ { "minimum": 152.18, "maximum": 507.62, "gross_charge": 540.02, "discounted_cash": 297.01, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 313.21, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 294.85, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 432.02, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 457.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 157.15, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 259.21, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 323.47, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 322.93, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 507.62, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 475.22, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 152.18, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 459.02, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 405.02, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 190.25, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 367.21, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 507.62, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 422.84, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 294.85, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 429.32, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 405.02, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 475.22, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 313.21, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 294.85, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ETRAVIRINE 100 MG PO TABS", "drug_information": { "unit": "2.000000", "type": "UN" }, "code_information": [ { "code": "69315028520", "type": "NDC" } ], "standard_charges": [ { "minimum": 9.4, "maximum": 31.35, "gross_charge": 33.35, "discounted_cash": 18.34, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.34, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.21, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.68, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.25, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.7, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.01, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.98, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.94, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.35, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.35, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.4, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.35, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.01, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.68, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.35, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.11, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.21, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.51, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.01, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.35, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.34, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.21, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "EUCERIN ORIGINAL HEALING EX CREA", "drug_information": { "unit": "454.000000", "type": "GR" }, "code_information": [ { "code": "72140000021", "type": "NDC" } ], "standard_charges": [ { "minimum": 7.22, "maximum": 24.09, "gross_charge": 25.63, "discounted_cash": 14.1, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.87, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.99, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.5, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.71, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.46, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.3, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.35, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.33, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.09, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.55, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.22, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.79, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.22, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.03, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.43, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.09, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.07, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.99, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.38, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.22, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.55, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.87, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.99, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Evasc rpr a-unilac ndgft", "code_information": [ { "code": "34703", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 78689.42, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 142783.3, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 142783.3, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Evasc rpr n/a a-iliac ndgft", "code_information": [ { "code": "34718", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 32218.52, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 58461.1, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 58461.1, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Evasc st rpr thrc/aa acrs br", "code_information": [ { "code": "33894", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 28570.43, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 51841.49, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 51841.49, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Evasc st rpr thrc/aa x crsg", "code_information": [ { "code": "33895", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 30185.31, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 54775.34, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 54775.34, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "EVEROLIMUS 0.25 MG PO TABS (IMMUNOSUPPRESSION)", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00078041720", "type": "NDC" } ], "standard_charges": [ { "minimum": 7.2, "maximum": 24.03, "gross_charge": 25.56, "discounted_cash": 14.06, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.82, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.96, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.65, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.44, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.27, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.31, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.28, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.03, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.49, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.2, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.73, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.17, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.0, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.38, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.03, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.01, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.96, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.32, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.17, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.49, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.82, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.96, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "EVEROLIMUS 0.5 MG PO TABS (IMMUNOSUPPRESSION)", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00078041420", "type": "NDC" } ], "standard_charges": [ { "minimum": 14.41, "maximum": 48.05, "gross_charge": 51.12, "discounted_cash": 28.12, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.65, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.91, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.9, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.3, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.88, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.54, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.62, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.57, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 48.05, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 44.99, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.41, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.45, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.34, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.01, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.76, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 48.05, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.03, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.91, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.64, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.34, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 44.99, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.65, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.91, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "EVEROLIMUS 0.75 MG PO TABS (IMMUNOSUPPRESSION)", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00078041520", "type": "NDC" } ], "standard_charges": [ { "minimum": 21.61, "maximum": 72.08, "gross_charge": 76.68, "discounted_cash": 42.17, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 44.47, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.87, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.34, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 64.95, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.31, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.81, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.93, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.85, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 72.08, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 67.48, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.61, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.18, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 57.51, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.01, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.14, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 72.08, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.04, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.87, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.96, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 57.51, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 67.48, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 44.47, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.87, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "EVEROLIMUS 1 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00078042220", "type": "NDC" } ], "standard_charges": [ { "minimum": 26.9, "maximum": 89.73, "gross_charge": 95.46, "discounted_cash": 52.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.37, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.12, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 76.37, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 80.85, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.78, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.82, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 57.18, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 57.09, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 89.73, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 84.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.9, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 81.14, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 71.6, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.63, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 64.91, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 89.73, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.75, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.12, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.89, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 71.6, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 84.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.37, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.12, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "EVEROLIMUS 10 MG PO TABS (CHEMO)", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00078056751", "type": "NDC" } ], "standard_charges": [ { "minimum": 751.54, "maximum": 2506.91, "gross_charge": 2666.93, "discounted_cash": 1466.81, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1546.82, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1456.14, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2133.54, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2258.89, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 776.08, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1280.13, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1597.49, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 1594.82, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2506.91, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2346.9, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 751.54, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2266.89, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2000.2, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 939.56, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1813.51, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2506.91, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2088.21, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1456.14, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2120.21, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2000.2, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2346.9, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1546.82, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1456.14, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "EVEROLIMUS 2.5 MG PO TABS (CHEMO)", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00078059451", "type": "NDC" } ], "standard_charges": [ { "minimum": 718.5, "maximum": 2396.71, "gross_charge": 2549.69, "discounted_cash": 1402.33, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1478.82, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1392.13, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2039.75, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2159.59, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 741.96, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1223.85, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1527.26, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 1524.71, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2396.71, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2243.73, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 718.5, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2167.24, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1912.27, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 898.26, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1733.79, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2396.71, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1996.41, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1392.13, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2027.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1912.27, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2243.73, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1478.82, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1392.13, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "EVEROLIMUS 5 MG PO TABS (CHEMO)", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "51991082228", "type": "NDC" } ], "standard_charges": [ { "minimum": 48.13, "maximum": 160.54, "gross_charge": 170.79, "discounted_cash": 93.93, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 99.06, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.25, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 136.63, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 144.66, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.7, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 81.98, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 102.3, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 102.13, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 160.54, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 150.3, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 48.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 145.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 128.09, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.17, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 116.14, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 160.54, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 133.73, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.25, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 135.78, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 128.09, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 150.3, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 99.06, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.25, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Ex arm/elbow tum deep < 5 cm", "code_information": [ { "code": "24076", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2109.62, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1562.68, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 5386.56, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 9774.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2109.62, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 9774.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Ex arm/elbow tum deep 5 cm/>", "code_information": [ { "code": "24073", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2109.62, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1562.68, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 10446.08, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 18954.58, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2109.62, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 18954.58, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Exam of cervix w/scope", "code_information": [ { "code": "57452", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 148.28, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 109.84, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 394.81, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 716.4, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 148.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 716.4, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Exam of vagina w/scope", "code_information": [ { "code": "57420", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 224.22, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 2587.13, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 4698.93, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 224.22, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 4698.93, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Exam of vulva w/scope", "code_information": [ { "code": "56820", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 148.28, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 109.84, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 8950.32, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 16240.5, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 148.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 16240.5, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Exam/biopsy of vag w/scope", "code_information": [ { "code": "57421", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 641.82, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 475.42, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 7818.87, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 14187.47, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 641.82, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 14187.47, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Exam/biopsy of vulva w/scope", "code_information": [ { "code": "56821", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 224.22, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 2587.13, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 4698.93, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 224.22, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 4698.93, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Exc abd les sc < 3 cm", "code_information": [ { "code": "22902", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1194.28, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 884.65, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 9144.77, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 16593.35, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1194.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 16593.35, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Exc abd les sc 3 cm/>", "code_information": [ { "code": "22903", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2109.62, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1562.68, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 6341.35, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 11506.5, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2109.62, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 11506.5, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Exc abd tum over 10 cm", "code_information": [ { "code": "49205", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 14615.7, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 26520.44, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 26520.44, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Exc abd tum over 5 cm", "code_information": [ { "code": "49204", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 6250.59, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 12304.8, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 12304.8, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Exc abdl tum deep < 5 cm", "code_information": [ { "code": "22900", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2109.62, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1562.68, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 6869.6, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 12465.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2109.62, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 12465.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Exc abdl tum deep 5 cm/>", "code_information": [ { "code": "22901", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2109.62, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1562.68, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 19403.01, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 35207.07, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2109.62, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 35207.07, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Exc arm/elbow les sc < 3 cm", "code_information": [ { "code": "24075", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1194.28, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 884.65, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 6023.33, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 10929.43, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1194.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 10929.43, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Exc arm/elbow les sc 3 cm/>", "code_information": [ { "code": "24071", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2109.62, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1562.68, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 7192.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 13050.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2109.62, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 13050.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Exc back les sc < 3 cm", "code_information": [ { "code": "21930", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1194.28, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 884.65, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 4483.84, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 8136.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1194.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 8136.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Exc back les sc 3 cm/>", "code_information": [ { "code": "21931", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1194.28, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 884.65, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 6250.59, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 11341.8, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1194.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 11341.8, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Exc back tum deep < 5 cm", "code_information": [ { "code": "21932", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2109.62, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1562.68, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 6815.04, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 12366.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2109.62, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 12366.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Exc back tum deep 5 cm/>", "code_information": [ { "code": "21933", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2109.62, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1562.68, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 6974.75, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 12655.8, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2109.62, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 12655.8, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Exc chest wall tumor w/ribs", "code_information": [ { "code": "21601", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2109.62, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1562.68, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 12870.61, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 23353.93, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2109.62, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 23353.93, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Exc f/e/e/n/l mal+mrg >4 cm", "code_information": [ { "code": "11646", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2109.62, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1562.68, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 8058.12, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 14621.58, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2109.62, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 14621.58, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Exc f/e/e/n/l mal+mrg 0.5cm<", "code_information": [ { "code": "11640", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 518.62, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 1168.68, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 2120.58, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 518.62, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 2120.58, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Exc f/e/e/n/l mal+mrg 0.6-1", "code_information": [ { "code": "11641", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 518.62, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 384.16, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 5034.4, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 9135.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 518.62, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 9135.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Exc f/e/e/n/l mal+mrg 1.1-2", "code_information": [ { "code": "11642", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 518.62, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 384.16, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 6937.16, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 12587.58, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 518.62, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 12587.58, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Exc f/e/e/n/l mal+mrg 2.1-3", "code_information": [ { "code": "11643", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1194.28, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 884.65, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 4199.24, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 7619.58, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1194.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 7619.58, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Exc f/e/e/n/l mal+mrg 3.1-4", "code_information": [ { "code": "11644", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1194.28, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 884.65, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 10401.72, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 18874.08, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1194.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 18874.08, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Exc face les sbq 2 cm/>", "code_information": [ { "code": "21012", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1194.28, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 884.65, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 7810.27, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 14171.85, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1194.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 14171.85, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Exc face les sc <2 cm", "code_information": [ { "code": "21011", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1194.28, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 884.65, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 9810.21, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 17800.78, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1194.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 17800.78, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Exc face tum deep < 2 cm", "code_information": [ { "code": "21013", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1194.28, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 884.65, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 3756.7, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 6816.6, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1194.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 6816.6, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Exc face tum deep 2 cm/>", "code_information": [ { "code": "21014", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2109.62, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1562.68, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 5942.08, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 11322.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2109.62, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 11322.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Exc foot/toe tum deep <1.5cm", "code_information": [ { "code": "28045", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2109.62, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1562.68, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 6983.18, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 12671.1, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2109.62, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 12671.1, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Exc foot/toe tum dep 1.5cm/>", "code_information": [ { "code": "28041", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2109.62, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1562.68, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 6819.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 13183.2, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2109.62, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 13183.2, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Exc foot/toe tum sc < 1.5 cm", "code_information": [ { "code": "28043", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1194.28, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 884.65, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 5661.84, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 10273.5, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1194.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 10273.5, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Exc foot/toe tum sc 1.5 cm/>", "code_information": [ { "code": "28039", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2109.62, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1562.68, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 5653.73, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 10258.78, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2109.62, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 10258.78, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Exc forearm les sc < 3 cm", "code_information": [ { "code": "25075", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1194.28, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 884.65, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 7312.03, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 13267.8, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1194.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 13267.8, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Exc forearm les sc 3 cm/>", "code_information": [ { "code": "25071", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1194.28, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 884.65, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 7380.47, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 13392.01, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1194.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 13392.01, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Exc forearm tum deep < 3 cm", "code_information": [ { "code": "25076", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1194.28, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 884.65, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 6534.54, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 11857.05, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1194.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 11857.05, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Exc forearm tum deep 3 cm/>", "code_information": [ { "code": "25073", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2109.62, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1562.68, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 12077.09, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 21914.09, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2109.62, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 21914.09, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Exc h-f-nk-sp mal+marg 0.5/<", "code_information": [ { "code": "11620", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1194.28, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 884.65, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 24053.99, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 43646.35, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1194.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 43646.35, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Exc hand les sc < 1.5 cm", "code_information": [ { "code": "26115", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1194.28, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 884.65, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 5784.34, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 10495.8, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1194.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 10495.8, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Exc hand les sc 1.5 cm/>", "code_information": [ { "code": "26111", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1194.28, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 884.65, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 6271.91, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 11663.1, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1194.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 11663.1, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Exc hand tum deep < 1.5 cm", "code_information": [ { "code": "26116", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1194.28, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 884.65, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 5077.12, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 9212.51, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1194.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 9212.51, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Exc hand tum deep 1.5 cm/>", "code_information": [ { "code": "26113", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1194.28, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 884.65, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 5666.52, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 12798.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1194.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 12798.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Exc hip pelvis les sc 3 cm/>", "code_information": [ { "code": "27043", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2109.62, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1562.68, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 4478.88, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 8127.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2109.62, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 8127.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Exc hip/pelv tum deep < 5 cm", "code_information": [ { "code": "27048", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2109.62, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1562.68, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 10231.13, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 18564.55, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2109.62, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 18564.55, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Exc hip/pelv tum deep 5 cm/>", "code_information": [ { "code": "27045", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2109.62, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1562.68, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 10625.49, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 19280.12, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2109.62, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 19280.12, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Exc hip/pelvis les sc < 3 cm", "code_information": [ { "code": "27047", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2109.62, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1562.68, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 4235.84, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 7686.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2109.62, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 7686.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Exc leg/ankle les sc 3 cm/>", "code_information": [ { "code": "27632", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2109.62, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1562.68, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 8620.47, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 15662.21, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2109.62, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 15662.21, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Exc leg/ankle tum < 3 cm", "code_information": [ { "code": "27618", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1194.28, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 884.65, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 6303.67, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 11438.1, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1194.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 11438.1, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Exc leg/ankle tum deep <5 cm", "code_information": [ { "code": "27619", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2109.62, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1562.68, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 7655.76, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 13891.5, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2109.62, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 13891.5, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Exc leg/ankle tum dep 5 cm/>", "code_information": [ { "code": "27634", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2109.62, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1562.68, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 7814.48, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 14179.5, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2109.62, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 14179.5, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Exc neck les sc < 3 cm", "code_information": [ { "code": "21555", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1194.28, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 884.65, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 7335.84, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 13311.02, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1194.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 13311.02, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Exc neck les sc 3 cm/>", "code_information": [ { "code": "21552", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2109.62, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1562.68, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 7335.84, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 13311.02, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2109.62, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 13311.02, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Exc neck tum deep < 5 cm", "code_information": [ { "code": "21556", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2109.62, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1562.68, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 8556.07, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 15525.14, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2109.62, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 15525.14, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Exc neck tum deep 5 cm/>", "code_information": [ { "code": "21554", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2109.62, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1562.68, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 13200.92, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 23953.29, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2109.62, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 23953.29, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Exc neuroma w/ implnt nv end", "code_information": [ { "code": "C7551", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 16886.04, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 30639.99, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 30639.99, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Exc rect tum transanal full", "code_information": [ { "code": "45172", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2021.42, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1497.34, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 9046.45, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 16414.92, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2021.42, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 16414.92, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Exc rect tum transanal part", "code_information": [ { "code": "45171", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2021.42, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1497.34, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 5540.6, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 10064.51, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2021.42, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 10064.51, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Exc rectal tumor endoscopic", "code_information": [ { "code": "0184T", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4387.82, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3250.23, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 8676.15, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 15743.01, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4387.82, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 15743.01, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Exc s/n/h/f/g mal+mrg >4 cm", "code_information": [ { "code": "11626", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2109.62, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1562.68, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 14925.22, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 27087.61, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2109.62, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 27087.61, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Exc s/n/h/f/g mal+mrg 0.6-1", "code_information": [ { "code": "11621", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 518.62, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 384.16, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 6579.06, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 11937.81, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 518.62, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 11937.81, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Exc s/n/h/f/g mal+mrg 1.1-2", "code_information": [ { "code": "11622", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 518.62, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 384.16, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 5728.8, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 10395.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 518.62, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 10395.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Exc s/n/h/f/g mal+mrg 2.1-3", "code_information": [ { "code": "11623", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1194.28, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 884.65, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 4707.04, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 8541.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1194.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 8541.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Exc s/n/h/f/g mal+mrg 3.1-4", "code_information": [ { "code": "11624", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1194.28, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 884.65, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 7752.48, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 14067.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1194.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 14067.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Exc shoulder les sc < 3 cm", "code_information": [ { "code": "23075", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1194.28, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 884.65, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 9950.58, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 20215.46, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1194.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 20215.46, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Exc shoulder les sc 3 cm/>", "code_information": [ { "code": "23071", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1194.28, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 884.65, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 7193.98, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 13053.6, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1194.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 13053.6, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Exc shoulder tum deep < 5 cm", "code_information": [ { "code": "23076", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2109.62, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1562.68, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 8305.27, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 16941.93, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2109.62, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 16941.93, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Exc shoulder tum deep 5 cm/>", "code_information": [ { "code": "23073", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2109.62, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1562.68, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 8898.49, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 16162.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2109.62, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 16162.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Exc skin abd", "code_information": [ { "code": "15830", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4806.97, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3560.72, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 17315.35, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 32555.09, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4806.97, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 32555.09, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Exc skn h/p/p/u smpl/ntrm", "code_information": [ { "code": "11470", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2109.62, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1562.68, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 7275.9, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 13202.24, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2109.62, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 13202.24, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Exc skn hdrdnt ax smpl/ntrm", "code_information": [ { "code": "11450", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2109.62, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1562.68, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 6968.8, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 12652.2, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2109.62, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 12652.2, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Exc thigh/knee les sc < 3 cm", "code_information": [ { "code": "27327", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1194.28, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 884.65, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 7273.84, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 13468.5, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1194.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 13468.5, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Exc thigh/knee les sc 3 cm/>", "code_information": [ { "code": "27337", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2109.62, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1562.68, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 7239.61, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 13136.4, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2109.62, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 13136.4, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Exc thigh/knee tum deep <5cm", "code_information": [ { "code": "27328", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2109.62, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1562.68, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 11853.09, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 21507.62, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2109.62, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 21507.62, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Exc thigh/knee tum dep 5cm/>", "code_information": [ { "code": "27339", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2109.62, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1562.68, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 11404.6, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 20693.84, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2109.62, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 20693.84, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Exc tr-ext mal+marg >4 cm", "code_information": [ { "code": "11606", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1194.28, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 884.65, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 7428.65, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 13479.41, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1194.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 13479.41, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Exc tr-ext mal+marg 0.5 cm/<", "code_information": [ { "code": "11600", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 518.62, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 384.16, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 4196.16, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 7614.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 518.62, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 7614.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Exc tr-ext mal+marg 0.6-1 cm", "code_information": [ { "code": "11601", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 518.62, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 4560.82, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 8275.68, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 518.62, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 8275.68, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Exc tr-ext mal+marg 1.1-2 cm", "code_information": [ { "code": "11602", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 294.49, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 1959.2, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 3555.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 294.49, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 3555.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Exc tr-ext mal+marg 2.1-3 cm", "code_information": [ { "code": "11603", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 518.62, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 2111.08, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 3830.58, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 518.62, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 3830.58, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Exc tr-ext mal+marg 3.1-4 cm", "code_information": [ { "code": "11604", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 518.62, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 384.16, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 4196.16, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 7614.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 518.62, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 7614.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Exc/crtg b1 cst/b9 tum rds", "code_information": [ { "code": "24120", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2391.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1771.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 9642.88, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 17497.17, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2391.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 17497.17, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Exc/curtg b1 cst/b9 tum hum", "code_information": [ { "code": "24110", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2391.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1771.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 15300.53, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 27763.06, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2391.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 27763.06, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Exchange biliary drg cath", "code_information": [ { "code": "47536", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2601.27, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1926.87, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 11334.82, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 20574.42, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2601.27, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 20574.42, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Exchange drainage catheter", "code_information": [ { "code": "49423", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1398.27, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1035.76, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 5930.99, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 10761.88, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1398.27, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 10761.88, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Exchange lens prosthesis", "code_information": [ { "code": "66986", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1681.13, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1245.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 7402.95, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 13432.77, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1681.13, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 13432.77, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Exchange nephrostomy cath", "code_information": [ { "code": "50435", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1509.96, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1118.49, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 8249.86, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 14969.53, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1509.96, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 14969.53, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Excis uppr jaw cyst w/repair", "code_information": [ { "code": "21049", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4360.43, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3229.95, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 12395.12, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 23232.77, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4360.43, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 23232.77, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Excise anal ext tag/papilla", "code_information": [ { "code": "46220", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 869.1, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 643.78, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 4409.44, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 8001.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 869.1, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 8001.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Excise excess skin & tissue", "code_information": [ { "code": "15839", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2109.62, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1562.68, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 9731.52, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 18918.01, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2109.62, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 18918.01, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Excise excessive skin arm", "code_information": [ { "code": "15836", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2109.62, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1562.68, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 27648.65, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 50168.94, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2109.62, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 50168.94, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Excise excessive skin buttck", "code_information": [ { "code": "15835", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2109.62, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1562.68, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 17340.3, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 31464.26, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2109.62, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 31464.26, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Excise excessive skin hip", "code_information": [ { "code": "15834", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2109.62, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1562.68, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 27172.25, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 49304.53, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2109.62, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 49304.53, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Excise excessive skin thigh", "code_information": [ { "code": "15832", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2109.62, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1562.68, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 17567.34, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 31876.24, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2109.62, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 31876.24, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Excise inferior turbinate", "code_information": [ { "code": "30130", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2390.47, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1770.72, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 17966.39, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 32600.39, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2390.47, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 32600.39, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Excise intraspinl lesion crv", "code_information": [ { "code": "63265", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 5265.64, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3900.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 33036.06, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 61188.28, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5265.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 61188.28, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Excise intrspinl lesion lmbr", "code_information": [ { "code": "63267", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 5265.64, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3900.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 18064.9, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 32779.06, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5265.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 32779.06, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Excise intrspinl lesion thrc", "code_information": [ { "code": "63266", "type": "HCPCS" }, { "code": "63271", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 5265.64, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3900.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 30928.58, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 56120.4, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5265.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 56120.4, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Excise lesion testis", "code_information": [ { "code": "54512", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2542.24, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1883.14, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 10775.59, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 19563.51, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2542.24, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 19563.51, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Excise lip or cheek fold", "code_information": [ { "code": "40819", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1091.85, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 808.78, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 6524.63, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 11839.05, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1091.85, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 11839.05, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Excise lwr jaw cyst w/repair", "code_information": [ { "code": "21047", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4360.43, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3229.95, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 12395.12, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 23232.77, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4360.43, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 23232.77, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Excise mandible lesion", "code_information": [ { "code": "21040", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2390.47, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1770.72, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 12318.73, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 22352.54, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2390.47, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 22352.54, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Excise max/zygoma b9 tumor", "code_information": [ { "code": "21030", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4360.43, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3229.95, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 13160.87, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 23880.62, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4360.43, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 23880.62, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Excise max/zygoma mal tumor", "code_information": [ { "code": "21034", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4360.43, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3229.95, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 10235.75, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 18572.92, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4360.43, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 18572.92, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Excise oral mucosa for graft", "code_information": [ { "code": "40818", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 375.37, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 278.05, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 18351.85, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 33299.75, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 375.37, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 33299.75, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Excise parotid gland/lesion", "code_information": [ { "code": "42410", "type": "HCPCS" }, { "code": "42415", "type": "HCPCS" }, { "code": "42420", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4360.43, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3229.95, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 18117.07, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 32873.73, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4360.43, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 32873.73, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Excise pharynx lesion", "code_information": [ { "code": "42808", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2390.47, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1770.72, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 11186.95, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 20298.89, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2390.47, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 20298.89, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Excise sublingual gland", "code_information": [ { "code": "42450", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4360.43, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3229.95, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 15601.73, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 28309.6, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4360.43, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 28309.6, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Excise submaxillary gland", "code_information": [ { "code": "42440", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4360.43, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3229.95, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 20183.71, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 36623.7, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4360.43, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 36623.7, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Excise tendon forearm/wrist", "code_information": [ { "code": "25109", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2391.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1771.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 8907.17, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 16162.2, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2391.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 16162.2, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Excise wrist tendon sheath", "code_information": [ { "code": "25118", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1179.66, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 873.82, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 5308.19, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 9631.8, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1179.66, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 9631.8, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Excise/repair mouth lesion", "code_information": [ { "code": "40812", "type": "HCPCS" }, { "code": "40814", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2390.47, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 808.78, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1770.72, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 15681.73, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 28454.79, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1091.85, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2390.47, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 28454.79, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Excision breast lesion", "code_information": [ { "code": "19125", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2822.56, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2090.79, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 8063.35, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 14631.08, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2822.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 14631.08, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Excision lesion mouth roof", "code_information": [ { "code": "42104", "type": "HCPCS" }, { "code": "42106", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2390.47, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1770.72, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 7925.79, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 14381.48, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2390.47, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 14381.48, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Excision of anal lesion(s)", "code_information": [ { "code": "46922", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2021.42, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1497.34, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 6073.52, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 11020.5, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2021.42, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 11020.5, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Excision of bone lower jaw", "code_information": [ { "code": "21025", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4360.43, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3229.95, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 19340.59, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 35093.84, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4360.43, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 35093.84, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Excision of facial bone(s)", "code_information": [ { "code": "21026", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4360.43, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3229.95, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 24368.51, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 44217.08, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4360.43, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 44217.08, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Excision of gum lesion", "code_information": [ { "code": "41825", "type": "HCPCS" }, { "code": "41826", "type": "HCPCS" }, { "code": "41827", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4360.43, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1770.72, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3229.95, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 9650.18, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 17510.4, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2390.47, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4360.43, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 17510.4, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Excision of lingual tonsil", "code_information": [ { "code": "42870", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4360.43, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3229.95, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 15883.71, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 28821.31, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4360.43, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 28821.31, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Excision of mouth lesion", "code_information": [ { "code": "40810", "type": "HCPCS" }, { "code": "40816", "type": "HCPCS" }, { "code": "41116", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2390.47, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1770.72, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 2901.6, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 5544.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2390.47, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 5544.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Excision of neck cyst", "code_information": [ { "code": "42810", "type": "HCPCS" }, { "code": "42815", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4360.43, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1770.72, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3229.95, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 7042.43, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 12778.59, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2390.47, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4360.43, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 12778.59, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Excision of penis lesion(s)", "code_information": [ { "code": "54060", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1348.33, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 998.76, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 6824.95, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 15040.11, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1348.33, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 15040.11, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Excision of rectal prolapse", "code_information": [ { "code": "45130", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 14157.82, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 25689.6, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 25689.6, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Excision of salivary cyst", "code_information": [ { "code": "42408", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2390.47, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1770.72, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 16231.66, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 29452.63, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2390.47, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 29452.63, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Excision of tongue fold", "code_information": [ { "code": "41115", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1091.85, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 808.78, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 7930.61, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 14390.21, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1091.85, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 14390.21, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Excision of tongue lesion", "code_information": [ { "code": "41110", "type": "HCPCS" }, { "code": "41112", "type": "HCPCS" }, { "code": "41113", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2390.47, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1770.72, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 8556.99, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 15526.8, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2390.47, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 15526.8, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Excision of umbilicus", "code_information": [ { "code": "49250", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2601.27, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1926.87, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 15605.67, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 28316.7, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2601.27, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 28316.7, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Excision of uvula", "code_information": [ { "code": "42140", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2390.47, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1770.72, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 23363.43, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 42393.27, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2390.47, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 42393.27, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Excision olecranon bursa", "code_information": [ { "code": "24105", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2391.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1771.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 8887.4, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 16126.33, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2391.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 16126.33, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Excision radial head", "code_information": [ { "code": "24130", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2391.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1771.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 28081.94, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 50955.12, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2391.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 50955.12, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "EXEMESTANE 25 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "59762285801", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Expl n/flwd surg lxtr art", "code_information": [ { "code": "35703", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 23157.83, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 42020.35, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 42020.35, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Expl n/flwd surg uxtr art", "code_information": [ { "code": "35702", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 19342.92, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 35119.65, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 35119.65, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Exploration behind upper jaw", "code_information": [ { "code": "31040", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4360.43, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3229.95, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 13044.01, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 23668.56, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4360.43, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 23668.56, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Exploration maxillary sinus", "code_information": [ { "code": "31020", "type": "HCPCS" }, { "code": "31030", "type": "HCPCS" }, { "code": "31256", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4360.43, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1770.72, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3229.95, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2013.07, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 10984.48, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 19931.52, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2390.47, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4360.43, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2717.65, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 19931.52, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Exploration of ankle joint", "code_information": [ { "code": "27612", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2391.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1771.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 22410.55, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 40664.35, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2391.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 40664.35, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Exploration of chest", "code_information": [ { "code": "39000", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 24590.22, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 44619.37, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 44619.37, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Exploration of foot joint", "code_information": [ { "code": "28022", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2391.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1771.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 7690.48, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 13954.5, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2391.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 13954.5, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Exploration of frontal sinus", "code_information": [ { "code": "31075", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4360.43, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3229.95, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 9334.46, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 20092.7, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4360.43, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 20092.7, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Exploration of knee joint", "code_information": [ { "code": "27310", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2391.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1771.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 77312.63, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 140443.48, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2391.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 140443.48, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Exploration of middle ear", "code_information": [ { "code": "69440", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2390.47, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1770.72, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 10317.22, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 18720.79, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2390.47, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 18720.79, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Exploration of toe joint", "code_information": [ { "code": "28024", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1179.66, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 873.82, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 6155.86, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 11169.9, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1179.66, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 11169.9, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Exploratory shoulder surgery", "code_information": [ { "code": "23040", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2391.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1771.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 14685.43, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 26646.98, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2391.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 26646.98, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Explore adrenal gland", "code_information": [ { "code": "60540", "type": "HCPCS" }, { "code": "60545", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 24236.32, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 43977.23, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 43977.23, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Explore deep node(s) neck", "code_information": [ { "code": "38542", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4300.51, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3185.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 18108.58, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 32858.35, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4300.51, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 32858.35, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Explore inner ear", "code_information": [ { "code": "69805", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4360.43, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3229.95, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 16991.72, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 30831.74, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4360.43, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 30831.74, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Explore neck vessels", "code_information": [ { "code": "35800", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 54488.2, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 99649.87, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 99649.87, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Explore parathyroid glands", "code_information": [ { "code": "60500", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4360.43, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3229.95, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 14656.27, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 26594.04, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4360.43, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 26594.04, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Explore sinus remove polyps", "code_information": [ { "code": "31032", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4360.43, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3229.95, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 11887.57, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 21570.2, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4360.43, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 21570.2, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Explore treat shoulder joint", "code_information": [ { "code": "23107", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 5265.64, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3900.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 11507.94, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 20881.35, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5265.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 20881.35, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Explore/biopsy eye socket", "code_information": [ { "code": "67400", "type": "HCPCS" }, { "code": "67450", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2779.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2058.97, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 9118.29, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 16545.28, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2779.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 16545.28, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Explore/drain eye socket", "code_information": [ { "code": "67405", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1719.62, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1273.8, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 16236.36, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 29697.01, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1719.62, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 29697.01, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Explore/irrigate tear ducts", "code_information": [ { "code": "68840", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 220.34, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 163.22, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 2046.32, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 3713.09, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 220.34, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 3713.09, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Explore/treat eye socket", "code_information": [ { "code": "67412", "type": "HCPCS" }, { "code": "67413", "type": "HCPCS" }, { "code": "67420", "type": "HCPCS" }, { "code": "67430", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2779.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1273.8, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2058.97, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 9625.47, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 17465.56, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1719.62, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2779.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 17465.56, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Explore/treat finger joint", "code_information": [ { "code": "26075", "type": "HCPCS" }, { "code": "26080", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2391.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1771.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 873.82, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 21012.04, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 38126.69, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2391.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1179.66, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 38126.69, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Explore/treat knee joint", "code_information": [ { "code": "27331", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2391.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1771.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 14155.28, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 25684.97, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2391.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 25684.97, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Explore/treat wrist joint", "code_information": [ { "code": "25101", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2391.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1771.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 11033.52, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 20372.4, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2391.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 20372.4, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Explr/decompress eye socket", "code_information": [ { "code": "67414", "type": "HCPCS" }, { "code": "67445", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2779.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2058.97, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 11194.96, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 20313.43, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2779.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 20313.43, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Extensive ear canal surgery", "code_information": [ { "code": "69150", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4360.43, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3229.95, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 11865.31, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 21529.78, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4360.43, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 21529.78, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Extensive mastoid surgery", "code_information": [ { "code": "69530", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4360.43, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3229.95, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 31642.71, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 57945.05, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4360.43, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 57945.05, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Extensive prostate surgery", "code_information": [ { "code": "55845", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 42584.57, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 80313.78, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 80313.78, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Extensive thyroid surgery", "code_information": [ { "code": "60254", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 31805.11, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 57710.88, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 57710.88, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Extensive vulva surgery", "code_information": [ { "code": "56632", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 33989.5, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 61674.55, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 61674.55, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Extraction of lens", "code_information": [ { "code": "66930", "type": "HCPCS" }, { "code": "66940", "type": "HCPCS" }, { "code": "66920", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2965.25, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2196.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1245.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 27537.52, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 51833.02, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2965.25, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1681.13, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 51833.02, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "EYE WASH OP SOLN", "drug_information": { "unit": "118.000000", "type": "UN" }, "code_information": [ { "code": "10119000252", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "EZETIMIBE 10 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "50268029812", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.15, "maximum": 7.18, "gross_charge": 7.64, "discounted_cash": 4.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.43, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.17, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.11, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.47, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.22, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.67, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.58, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.57, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.18, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.72, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.15, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.49, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.73, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.69, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.18, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.98, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.17, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.07, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.73, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.72, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.43, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.17, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "EZETIMIBE-SIMVASTATIN 10-10 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "67877050730", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "EZETIMIBE-SIMVASTATIN 10-20 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "67877050830", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "EZETIMIBE-SIMVASTATIN 10-40 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68462032330", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "EZETIMIBE-SIMVASTATIN 10-80 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68462032430", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Face bone graft", "code_information": [ { "code": "21210", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4360.43, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3229.95, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 20845.01, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 37823.58, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4360.43, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 37823.58, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "FAMCICLOVIR 250 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "31722070730", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "FAMCICLOVIR 500 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00093811956", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.06, "maximum": 6.87, "gross_charge": 7.31, "discounted_cash": 4.02, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.24, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.99, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.85, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.19, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.13, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.51, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.38, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.87, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.43, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.06, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.21, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.48, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.58, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.97, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.87, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.72, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.99, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.81, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.48, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.43, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.24, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.99, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "FAMOTIDINE (PF) 20 MG/2ML IV SOLN", "drug_information": { "unit": "2.000000", "type": "UN" }, "code_information": [ { "code": "67457043322", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 1158.0, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.72, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "FAMOTIDINE 10 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "R6800149404", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "FAMOTIDINE 20 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687059501", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "FAMOTIDINE 20 MG/2.5ML PO SUSR", "drug_information": { "unit": "2.500000", "type": "UN" }, "code_information": [ { "code": "0574014704", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "FAMOTIDINE 20 MG/50 ML RTU", "drug_information": { "unit": "50.000000", "type": "UN" }, "code_information": [ { "code": "00338519741", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 1158.0, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 95.48, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "FAMOTIDINE 40 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "50268030415", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "FAMOTIDINE 40 MG/5ML PO SUSR", "drug_information": { "unit": "50.000000", "type": "UN" }, "code_information": [ { "code": "00832604550", "type": "NDC" } ], "standard_charges": [ { "minimum": 15.57, "maximum": 51.94, "gross_charge": 55.25, "discounted_cash": 30.39, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.05, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.17, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 44.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.8, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.08, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.52, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.09, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.04, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 51.94, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 48.62, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.57, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.96, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.44, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.46, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.57, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 51.94, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.26, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.17, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.92, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.44, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 48.62, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.05, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.17, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "FARICIMAB-SVOA 6 MG/0.05ML IZ SOLN", "drug_information": { "unit": "0.050000", "type": "UN" }, "code_information": [ { "code": "50242009601", "type": "NDC" } ], "standard_charges": [ { "minimum": 18.7, "maximum": 6299.32, "gross_charge": 6701.4, "discounted_cash": 3685.77, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3886.81, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.7, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5361.12, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5676.09, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1950.11, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3216.67, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4014.14, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4007.44, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6299.32, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5897.23, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1888.45, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5696.19, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5026.05, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2360.9, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4556.95, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6299.32, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5247.2, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.25, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5327.61, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5026.05, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5897.23, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3886.81, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.7, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "FARICIMAB-SVOA 6 MG/0.05ML IZ SOSY", "drug_information": { "unit": "0.050000", "type": "UN" }, "code_information": [ { "code": "50242009606", "type": "NDC" } ], "standard_charges": [ { "minimum": 18.7, "maximum": 6299.32, "gross_charge": 6701.4, "discounted_cash": 3685.77, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3886.81, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.7, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5361.12, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5676.09, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1950.11, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3216.67, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4014.14, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4007.44, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6299.32, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5897.23, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1888.45, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5696.19, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5026.05, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2360.9, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4556.95, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6299.32, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5247.2, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.25, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5327.61, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5026.05, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5897.23, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3886.81, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.7, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "FAT EMUL FISH OIL/PLANT BASED 20 % IV BAG (NICU/PEDS)", "drug_information": { "unit": "250.000000", "type": "UN" }, "code_information": [ { "code": "63323082074", "type": "NDC" } ], "standard_charges": [ { "minimum": 36.63, "maximum": 1158.0, "gross_charge": 130.0, "discounted_cash": 71.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.4, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 70.98, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 112.84, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.83, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 62.4, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 77.87, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 77.74, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 122.2, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 114.4, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.63, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 110.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 97.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.8, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.4, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 122.2, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 101.79, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 70.98, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.35, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 97.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 114.4, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.4, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 70.98, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "FAT EMUL FISH OIL/PLANT BASED 20 % IV EMUL", "drug_information": { "unit": "250.000000", "type": "UN" }, "code_information": [ { "code": "63323082074_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 36.63, "maximum": 1158.0, "gross_charge": 130.0, "discounted_cash": 71.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.4, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 70.98, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 112.84, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.83, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 62.4, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 77.87, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 77.74, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 122.2, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 114.4, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.63, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 110.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 97.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.8, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.4, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 122.2, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 101.79, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 70.98, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.35, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 97.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 114.4, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.4, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 70.98, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "FAT EMUL FISH OIL/PLANT BASED 20 % IV SYRINGE (NICU/PEDS)", "drug_information": { "unit": "250.000000", "type": "UN" }, "code_information": [ { "code": "63323082074_3", "type": "NDC" } ], "standard_charges": [ { "minimum": 36.63, "maximum": 1158.0, "gross_charge": 130.0, "discounted_cash": 71.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.4, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 70.98, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 112.84, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.83, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 62.4, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 77.87, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 77.74, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 122.2, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 114.4, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.63, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 110.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 97.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.8, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.4, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 122.2, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 101.79, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 70.98, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.35, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 97.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 114.4, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.4, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 70.98, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "FAT EMULSION PLANT BASED (SOY) 20 % IV EMUL", "drug_information": { "unit": "250.000000", "type": "UN" }, "code_information": [ { "code": "00264446030", "type": "NDC" } ], "standard_charges": [ { "minimum": 36.63, "maximum": 1158.0, "gross_charge": 130.0, "discounted_cash": 71.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.4, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 70.98, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 112.84, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.83, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 62.4, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 77.87, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 77.74, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 122.2, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 114.4, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.63, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 110.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 97.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.8, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.4, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 122.2, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 101.79, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 70.98, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.35, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 97.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 114.4, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.4, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 70.98, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "FAT EMULSION PLANT BASED (SOY) 20 % IV EMUL BAG (NICU/PEDS)", "drug_information": { "unit": "100.000000", "type": "UN" }, "code_information": [ { "code": "65219053110", "type": "NDC" } ], "standard_charges": [ { "minimum": 29.87, "maximum": 1158.0, "gross_charge": 106.0, "discounted_cash": 58.3, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.48, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 57.88, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 92.01, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.85, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.88, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.49, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 99.64, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.28, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.87, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 90.1, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 79.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.34, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 72.08, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 99.64, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 83.0, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 57.88, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 84.27, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 79.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.28, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.48, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 57.88, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "FAT EMULSION PLANT BASED (SOY) 20 % IV EMUL SYRINGE (NICU/PEDS)", "drug_information": { "unit": "250.000000", "type": "UN" }, "code_information": [ { "code": "00264446030_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 36.63, "maximum": 1158.0, "gross_charge": 130.0, "discounted_cash": 71.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.4, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 70.98, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 112.84, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.83, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 62.4, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 77.87, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 77.74, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 122.2, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 114.4, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.63, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 110.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 97.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.8, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.4, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 122.2, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 101.79, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 70.98, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.35, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 97.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 114.4, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.4, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 70.98, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "FAT EMULSION PLANT BASED 20 % IV 250 ML (BULK CHARGE)", "drug_information": { "unit": "250.000000", "type": "UN" }, "code_information": [ { "code": "00264446030_3", "type": "NDC" } ], "standard_charges": [ { "minimum": 36.63, "maximum": 1158.0, "gross_charge": 130.0, "discounted_cash": 71.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.4, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 70.98, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 112.84, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.83, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 62.4, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 77.87, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 77.74, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 122.2, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 114.4, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.63, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 110.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 97.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.8, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.4, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 122.2, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 101.79, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 70.98, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.35, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 97.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 114.4, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.4, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 70.98, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "FEBUXOSTAT 40 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687053821", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "FEBUXOSTAT 80 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "72205002930", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "FECAL MICROBIOTA LIVE-JSLM 150 ML RE SUSP", "drug_information": { "unit": "150.000000", "type": "UN" }, "code_information": [ { "code": "55566980002", "type": "NDC" } ], "standard_charges": [ { "minimum": 34.56, "maximum": 25760.7, "gross_charge": 27405.0, "discounted_cash": 15072.75, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 15894.9, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21924.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23212.04, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7974.86, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13154.4, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 16415.6, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 11394.0, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 25760.7, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 24116.4, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 7722.73, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23294.25, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20553.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 9654.78, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 18635.4, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 25760.7, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21458.12, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.66, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 15189.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20553.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 24116.4, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 15894.9, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "FELBAMATE 400 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "62559073001", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "FELBAMATE 600 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "62559073101", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "FELBAMATE 600 MG/5ML PO SUSP", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "65162068688", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.78, "maximum": 9.26, "gross_charge": 9.85, "discounted_cash": 5.42, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.71, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.38, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.88, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.34, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.87, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.73, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.9, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.26, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.67, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.78, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.37, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.39, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.47, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.7, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.26, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.71, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.38, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.83, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.39, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.67, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.71, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.38, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "FELODIPINE ER 10 MG PO TB24", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "53489037001", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.28, "maximum": 4.28, "gross_charge": 4.55, "discounted_cash": 2.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.48, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.64, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.85, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.32, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.73, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.28, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.28, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.87, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.41, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.6, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.09, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.28, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.56, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.48, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.62, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.41, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.48, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "FELODIPINE ER 2.5 MG PO TB24", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00603358121", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "FELODIPINE ER 5 MG PO TB24", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "13668013301", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Fem/popl revas w/ather", "code_information": [ { "code": "37225", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 13235.9, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 9804.37, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 36520.4, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 66266.86, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 13235.9, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 66266.86, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Fem/popl revas w/tla", "code_information": [ { "code": "37224", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4202.59, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3113.03, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 30026.86, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 54484.26, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4202.59, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 54484.26, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Fem/popl revasc stnt & ather", "code_information": [ { "code": "37227", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 13235.9, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 9804.37, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 34418.92, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 62453.69, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 13235.9, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 62453.69, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Fem/popl revasc w/stent", "code_information": [ { "code": "37226", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 8359.13, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 6191.95, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 51102.08, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 92725.58, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8359.13, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 92725.58, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "FENOFIBRATE MICRONIZED 200 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687071321", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.23, "maximum": 7.44, "gross_charge": 7.92, "discounted_cash": 4.36, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.59, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.32, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.34, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.71, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.3, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.74, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.74, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.44, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.97, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.23, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.73, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.94, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.79, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.39, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.44, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.2, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.32, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.3, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.94, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.97, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.59, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.32, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "FENOFIBRATE MICRONIZED 67 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68462058001", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "FENTANYL 1 MG/100 ML RTU DRIP (MULTI-GPI) (FIXED RATE)", "drug_information": { "unit": "100.000000", "type": "UN" }, "code_information": [ { "code": "70092109236", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "FENTANYL 100 MCG/HR TD PT72", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00378912498", "type": "NDC" } ], "standard_charges": [ { "minimum": 15.12, "maximum": 50.42, "gross_charge": 53.64, "discounted_cash": 29.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.11, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.29, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.91, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.43, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.61, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.75, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.13, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.08, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.42, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.12, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.59, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.23, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.9, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.48, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.42, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.0, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.29, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.64, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.23, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.11, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.29, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "FENTANYL 1000 MCG/100 ML RTU DRIP (MULTI-GPI)(TITRATABLE RATE)", "drug_information": { "unit": "100.000000", "type": "UN" }, "code_information": [ { "code": "70092109236_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "FENTANYL 12 MCG/HR TD PT72", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00406911276", "type": "NDC" } ], "standard_charges": [ { "minimum": 10.36, "maximum": 34.57, "gross_charge": 36.78, "discounted_cash": 20.23, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.33, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.08, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.42, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.15, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.7, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.65, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.03, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.99, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.57, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.37, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.36, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.26, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.59, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.96, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.01, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.57, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.8, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.08, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.24, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.59, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.37, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.33, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.08, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "FENTANYL 2 MCG/1ML IN D5 SYRINGE BATCH (NICU)", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "08252000307", "type": "NDC" } ], "standard_charges": [ { "minimum": 12.68, "maximum": 42.3, "gross_charge": 45.0, "discounted_cash": 24.75, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.1, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.12, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.1, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.91, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.3, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.68, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.25, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.85, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.6, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.3, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.24, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.78, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.1, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "FENTANYL 25 MCG/HR TD PT72", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00378912198", "type": "NDC" } ], "standard_charges": [ { "minimum": 3.91, "maximum": 13.05, "gross_charge": 13.88, "discounted_cash": 7.63, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.05, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.58, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.1, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.76, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.04, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.66, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.31, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.3, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.05, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.21, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.91, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.8, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.41, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.89, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.44, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.05, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.87, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.58, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.03, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.41, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.21, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.05, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.58, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "FENTANYL 50 MCG/HR TD PT72", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00378912298", "type": "NDC" } ], "standard_charges": [ { "minimum": 6.95, "maximum": 23.17, "gross_charge": 24.65, "discounted_cash": 13.56, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.3, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.46, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.72, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.17, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.83, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.77, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.74, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.17, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.69, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.95, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.95, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.49, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.68, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.76, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.17, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.3, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.46, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.6, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.49, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.69, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.3, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.46, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "FENTANYL 50 MCG/ML DRIP SYRINGE 2 ML (NICU/PEDS)", "drug_information": { "unit": "2.000000", "type": "UN" }, "code_information": [ { "code": "00409909422_3", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "FENTANYL 50 MCG/ML DRIP SYRINGE 20 ML (NICU/PEDS)", "drug_information": { "unit": "20.000000", "type": "UN" }, "code_information": [ { "code": "00409909431_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "FENTANYL 50 MCG/ML DRIP SYRINGE 5 ML (NICU/PEDS)", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "00409909425_3", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "FENTANYL 50 MCG/ML DRIP SYRINGE 50 ML (NICU/PEDS)", "drug_information": { "unit": "50.000000", "type": "UN" }, "code_information": [ { "code": "00409909461_4", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "FENTANYL 50 MCG/ML INJ 2 ML (BULK CHARGE)", "drug_information": { "unit": "2.000000", "type": "UN" }, "code_information": [ { "code": "00409909422", "type": "NDC" } ], "standard_charges": [ { "minimum": 12.68, "maximum": 42.3, "gross_charge": 45.0, "discounted_cash": 24.75, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.1, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.12, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.1, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.91, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.3, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.68, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.25, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.85, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.6, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.3, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.24, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.78, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.1, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "FENTANYL 50 MCG/ML INJ 20ML (BULK CHARGE)", "drug_information": { "unit": "20.000000", "type": "UN" }, "code_information": [ { "code": "00409909431", "type": "NDC" } ], "standard_charges": [ { "minimum": 12.68, "maximum": 42.3, "gross_charge": 45.0, "discounted_cash": 24.75, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.1, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.12, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.1, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.91, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.3, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.68, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.25, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.85, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.6, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.3, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.24, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.78, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.1, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "FENTANYL 50 MCG/ML INJ 5ML (BULK CHARGE)", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "00409909425", "type": "NDC" } ], "standard_charges": [ { "minimum": 12.68, "maximum": 42.3, "gross_charge": 45.0, "discounted_cash": 24.75, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.1, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.12, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.1, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.91, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.3, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.68, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.25, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.85, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.6, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.3, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.24, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.78, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.1, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "FENTANYL 50 MCG/ML PCA SYRINGE", "drug_information": { "unit": "50.000000", "type": "UN" }, "code_information": [ { "code": "00409909461", "type": "NDC" } ], "standard_charges": [ { "minimum": 12.68, "maximum": 42.3, "gross_charge": 45.0, "discounted_cash": 24.75, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.1, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.12, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.1, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.91, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.3, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.68, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.25, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.85, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.6, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.3, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.24, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.78, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.1, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "FENTANYL 75 MCG/HR TD PT72", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00378912398", "type": "NDC" } ], "standard_charges": [ { "minimum": 10.98, "maximum": 36.62, "gross_charge": 38.96, "discounted_cash": 21.43, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.27, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.17, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.34, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.7, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.34, "standard_charge_percentage": 60.0, 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"percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.27, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "FENTANYL CITRATE (PF) 100 MCG/2ML IJ SOLN", "drug_information": { "unit": "2.000000", "type": "UN" }, "code_information": [ { "code": "00409909422_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 12.68, "maximum": 42.3, "gross_charge": 45.0, "discounted_cash": 24.75, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.1, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.12, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.1, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.91, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.3, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.68, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.25, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.85, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.6, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.3, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.24, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.78, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.1, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "FENTANYL CITRATE (PF) 1000 MCG/20ML IJ SOLN", "drug_information": { "unit": "20.000000", "type": "UN" }, "code_information": [ { "code": "63323080620", "type": "NDC" } ], "standard_charges": [ { "minimum": 12.68, "maximum": 42.3, "gross_charge": 45.0, "discounted_cash": 24.75, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.1, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.12, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.1, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.91, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.3, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.68, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.25, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.85, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.6, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.3, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.24, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.78, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.1, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "FENTANYL CITRATE (PF) 250 MCG/5ML IJ SOLN", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "00409909425_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 12.68, "maximum": 42.3, "gross_charge": 45.0, "discounted_cash": 24.75, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.1, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.12, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.1, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.91, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.3, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.68, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.25, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.85, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.6, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.3, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.24, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.78, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.1, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "FENTANYL CITRATE (PF) 2500 MCG/50ML IJ SOLN", "drug_information": { "unit": "50.000000", "type": "UN" }, "code_information": [ { "code": "00409909461_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 12.68, "maximum": 42.3, "gross_charge": 45.0, "discounted_cash": 24.75, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.1, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.12, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.1, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.91, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.3, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.68, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.25, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.85, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.6, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.3, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.24, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.78, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.1, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "FENTANYL CITRATE (PF) 50 MCG/ML IJ SOLN (MULTI GPI)", "drug_information": { "unit": "50.000000", "type": "UN" }, "code_information": [ { "code": "00409909461_3", "type": "NDC" } ], "standard_charges": [ { "minimum": 12.68, "maximum": 42.3, "gross_charge": 45.0, "discounted_cash": 24.75, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.1, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.12, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.1, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.91, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.3, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.68, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.25, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.85, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.6, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.3, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.24, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.78, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.1, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "FENTANYL CITRATE (PF) 500 MCG/10ML IJ SOLN", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "00409909428", "type": "NDC" } ], "standard_charges": [ { "minimum": 12.68, "maximum": 42.3, "gross_charge": 45.0, "discounted_cash": 24.75, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.1, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.12, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.1, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.91, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.3, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.68, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.25, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.85, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.6, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.3, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.24, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.78, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.1, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "FENTANYL CITRATE 1000 MCG/100ML IV SOLN", "drug_information": { "unit": "100.000000", "type": "UN" }, "code_information": [ { "code": "71266505001", "type": "NDC" } ], "standard_charges": [ { "minimum": 13.1, "maximum": 43.71, "gross_charge": 46.5, "discounted_cash": 25.58, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.97, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.39, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.53, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.32, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.85, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.81, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.71, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.92, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.1, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.53, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.88, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.38, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.62, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.71, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.41, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.39, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.97, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.88, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.92, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.97, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.39, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "FENTANYL CITRATE-NACL 1-0.9 MG/100ML-% IV SOLN", "drug_information": { "unit": "100.000000", "type": "UN" }, "code_information": [ { "code": "70092109236_3", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "FENTANYL-BUPIVACAINE-NACL 0.5-0.0625-0.9 MG/250ML-% EP SOLN", "drug_information": { "unit": "250.000000", "type": "UN" }, "code_information": [ { "code": "70092126937", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 1158.0, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 95.48, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "FERRIC SUBSULFATE 259 MG/GM EX SOLN", "drug_information": { "unit": "8.000000", "type": "GR" }, "code_information": [ { "code": "59365606500", "type": "NDC" } ], "standard_charges": [ { "minimum": 9.99, "maximum": 33.32, "gross_charge": 35.45, "discounted_cash": 19.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.56, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.36, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.36, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.03, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.32, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.02, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.23, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.2, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.32, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.99, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.13, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.59, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.49, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.11, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.32, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.76, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.36, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.59, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.56, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.36, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "FERRIC SUBSULFATE EX SOLN (MULTI-GPI)", "drug_information": { "unit": "8.000000", "type": "UN" }, "code_information": [ { "code": "48783011208", "type": "NDC" } ], "standard_charges": [ { "minimum": 12.47, "maximum": 1158.0, "gross_charge": 44.25, "discounted_cash": 24.34, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.67, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.16, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.41, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.88, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.24, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.51, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.46, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.94, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.47, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.61, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.19, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.59, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.09, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.65, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.16, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.19, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.94, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.67, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.16, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "FERROUS GLUCONATE 324 (38 FE) MG PO TABS (MULTI-GPI)", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "20555001900", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "FERROUS SULFATE 300 (60 FE) MG/5ML PO SOLN", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "00121053005", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.86, "maximum": 6.21, "gross_charge": 6.61, "discounted_cash": 3.64, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.83, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.61, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.29, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.6, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.17, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.95, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.21, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.82, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.86, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.62, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.96, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.33, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.49, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.21, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.18, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.61, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.25, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.96, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.82, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.83, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.61, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "FERROUS SULFATE 325 (65 FE) MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00904759161", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "FERROUS SULFATE 325 (65 FE) MG PO TBEC", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00245010801", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "FERROUS SULFATE 75 (15 FE) MG/ML PO SOLN", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "R6961807059", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "FERUMOXYTOL 510 MG/17ML IV SOLN", "drug_information": { "unit": "17.000000", "type": "UN" }, "code_information": [ { "code": "00781315401", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.19, "maximum": 730.05, "gross_charge": 776.65, "discounted_cash": 427.16, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 450.46, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.19, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 621.32, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 657.82, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 226.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 372.79, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 465.21, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 464.44, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 730.05, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 683.45, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 218.86, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 660.15, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 582.49, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 273.61, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 528.12, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 730.05, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 608.12, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.25, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 617.44, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 582.49, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 683.45, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 450.46, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.19, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "FESOTERODINE FUMARATE ER 4 MG PO TB24", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00069024230", "type": "NDC" } ], "standard_charges": [ { "minimum": 6.17, "maximum": 20.57, "gross_charge": 21.88, "discounted_cash": 12.03, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.69, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.95, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.5, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.53, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.37, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.5, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.11, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.08, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.57, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.25, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.17, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.6, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.41, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.71, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.88, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.57, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.95, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.39, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.41, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.25, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.69, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.95, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "FESOTERODINE FUMARATE ER 8 MG PO TB24", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00069024430", "type": "NDC" } ], "standard_charges": [ { "minimum": 6.17, "maximum": 20.57, "gross_charge": 21.88, "discounted_cash": 12.03, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.69, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.95, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.5, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.53, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.37, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.5, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.11, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.08, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.57, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.25, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.17, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.6, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.41, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.71, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.88, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.57, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.95, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.39, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.41, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.25, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.69, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.95, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "FEXOFENADINE HCL 180 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "1671489901", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "FEXOFENADINE HCL 60 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "R6800143900", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "FIBRINOGEN CONCENTRATE (HUMAN) IV SOLR", "drug_information": { "unit": "1.000000", "type": "ME" }, "code_information": [ { "code": "68982034701_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.61, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.61, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.82, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.61, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "FIBRINOGEN CONCENTRATE (HUMAN) IV SOLR|DISCARDED DRUG NOT ADMINISTERED", "drug_information": { "unit": "1.000000", "type": "ME" }, "code_information": [ { "code": "68982034701", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.55, "maximum": 1.84, "gross_charge": 1.96, "discounted_cash": 1.08, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.14, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.61, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.57, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.66, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.57, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.94, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.17, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.17, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.84, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.72, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.55, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.67, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.47, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.69, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.33, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.84, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.53, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.82, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.56, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.47, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.72, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.14, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.61, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "FIDAXOMICIN 200 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "52015008001", "type": "NDC" } ], "standard_charges": [ { "minimum": 109.01, "maximum": 363.62, "gross_charge": 386.83, "discounted_cash": 212.76, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 224.36, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 211.21, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 309.46, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 327.65, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 112.57, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 185.68, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 231.71, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 231.32, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 363.62, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 340.41, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 109.01, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 328.81, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 290.12, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 136.28, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 263.04, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 363.62, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 302.89, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 211.21, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 307.53, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 290.12, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 340.41, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 224.36, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 211.21, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "FILGRASTIM 300 MCG/0.5ML IJ SOSY", "drug_information": { "unit": "0.500000", "type": "UN" }, "code_information": [ { "code": "55513092410", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.55, "maximum": 1215.87, "gross_charge": 1293.48, "discounted_cash": 711.41, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 750.22, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.55, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1034.78, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1095.58, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 376.4, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 620.87, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 774.79, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 773.5, 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"plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 970.11, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 455.69, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 879.57, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1215.87, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1012.79, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.74, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1028.32, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 970.11, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1138.26, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 750.22, 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"standard_charge_dollar": 0.55, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 976.26, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1033.62, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 355.12, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 585.76, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 730.98, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 729.76, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1147.11, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1073.89, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 343.89, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1037.28, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 915.25, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 429.92, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 829.82, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", 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"additional_payer_notes": "N/A", "standard_charge_dollar": 1073.89, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 707.79, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.55, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "FILGRASTIM 480 MCG/0.8ML IJ SOSY", "drug_information": { "unit": "0.800000", "type": "UN" }, "code_information": [ { "code": "55513020910", "type": "NDC" } ], "standard_charges": [ { "minimum": 580.47, "maximum": 1936.29, "gross_charge": 2059.88, "discounted_cash": 1132.93, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1194.73, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1124.69, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1647.9, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1744.72, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 599.43, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 988.74, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1233.87, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 1231.81, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1936.29, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1812.69, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 580.47, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1750.9, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1544.91, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 725.7, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1400.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1936.29, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1612.89, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1124.69, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1637.6, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1544.91, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1812.69, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1194.73, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1124.69, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "FILGRASTIM-SNDZ 300 MCG/0.5ML IJ SOSY", "drug_information": { "unit": "0.500000", "type": "UN" }, "code_information": [ { "code": "61314031810", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.2, "maximum": 264.48, "gross_charge": 281.36, "discounted_cash": 154.75, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 163.19, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.2, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 225.09, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 238.31, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 81.88, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 135.05, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 168.53, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 168.25, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 264.48, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 247.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 79.29, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 239.16, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 211.02, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 99.12, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 191.32, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 264.48, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 220.3, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.27, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 223.68, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 211.02, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 247.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 163.19, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.2, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "FILGRASTIM-SNDZ 480 MCG/0.8ML IJ SOSY", "drug_information": { "unit": "0.800000", "type": "UN" }, "code_information": [ { "code": "61314032610", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.2, "maximum": 493.69, "gross_charge": 525.2, "discounted_cash": 288.86, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 304.62, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.2, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 420.16, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 444.84, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 152.83, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 252.1, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 314.59, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 314.07, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 493.69, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 462.18, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 148.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 446.42, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 393.9, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 185.03, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 357.14, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 493.69, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 411.23, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.27, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 417.53, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 393.9, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 462.18, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 304.62, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.2, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "FILGRASTIM-SNDZ SYRINGE (301-479 MCG)", "drug_information": { "unit": "0.800000", "type": "UN" }, "code_information": [ { "code": "61314032610_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.2, "maximum": 493.69, "gross_charge": 525.2, "discounted_cash": 288.86, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 304.62, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.2, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 420.16, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 444.84, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 152.83, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 252.1, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 314.59, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 314.07, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 493.69, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 462.18, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 148.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 446.42, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 393.9, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 185.03, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 357.14, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 493.69, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 411.23, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.27, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 417.53, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 393.9, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 462.18, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 304.62, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.2, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "FILGRASTIM-SNDZ SYRINGE (61-299 MCG)", "drug_information": { "unit": "0.500000", "type": "UN" }, "code_information": [ { "code": "61314031810_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.2, "maximum": 264.48, "gross_charge": 281.36, "discounted_cash": 154.75, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 163.19, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.2, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 225.09, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 238.31, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 81.88, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 135.05, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 168.53, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 168.25, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 264.48, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 247.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 79.29, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 239.16, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 211.02, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 99.12, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 191.32, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 264.48, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 220.3, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.27, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 223.68, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 211.02, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 247.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 163.19, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.2, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "FINASTERIDE 1 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "65862092730", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "FINASTERIDE 5 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687042801", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Finger tendon transfer", "code_information": [ { "code": "26497", "type": "HCPCS" }, { "code": "26498", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2391.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1771.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 14876.54, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 27203.08, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2391.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 27203.08, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "FINGOLIMOD HCL 0.5 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00078060715", "type": "NDC" } ], "standard_charges": [ { "minimum": 361.79, "maximum": 1206.83, "gross_charge": 1283.86, "discounted_cash": 706.12, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 744.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 700.99, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1027.09, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1087.43, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 373.6, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 616.25, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 769.03, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 767.75, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1206.83, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1129.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 361.79, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1091.28, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 962.9, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 452.3, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 873.02, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1206.83, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1005.26, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 700.99, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1020.67, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 962.9, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1129.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 744.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 700.99, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "FIRST-MOUTHWASH BLM MT SUSP", "drug_information": { "unit": "15.000000", "type": "UN" }, "code_information": [ { "code": "R6562805001", "type": "NDC" } ], "standard_charges": [ { "minimum": 3.83, "maximum": 12.77, "gross_charge": 13.59, "discounted_cash": 7.47, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.88, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.42, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.87, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.51, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.95, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.52, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.14, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.13, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.77, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.96, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.83, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.55, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.19, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.79, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.24, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.77, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.64, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.42, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.19, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.96, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.88, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.42, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "FISH OIL 1000 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "77333030810", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "FISH OIL TRIGLYCERIDES 10 GM/100ML IV EMUL", "drug_information": { "unit": "100.000000", "type": "UN" }, "code_information": [ { "code": "63323020500", "type": "NDC" } ], "standard_charges": [ { "minimum": 65.63, "maximum": 1158.0, "gross_charge": 232.91, "discounted_cash": 128.1, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 135.09, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 127.17, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 202.17, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 67.78, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 111.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 139.51, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 139.28, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 218.94, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 204.96, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.63, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 197.97, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 174.68, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.05, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 158.38, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 218.94, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 182.37, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 127.17, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 185.16, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 174.68, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 204.96, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 135.09, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 127.17, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "FISH OIL TRIGLYCERIDES 5 GM/50ML IV EMUL", "drug_information": { "unit": "50.000000", "type": "UN" }, "code_information": [ { "code": "63323020550", "type": "NDC" } ], "standard_charges": [ { "minimum": 45.96, "maximum": 1158.0, "gross_charge": 163.08, "discounted_cash": 89.69, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 94.59, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 89.04, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 141.55, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.46, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 78.28, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 97.68, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 97.52, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 153.3, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 143.51, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.96, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 138.62, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 122.31, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 57.45, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 110.89, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 153.3, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 127.69, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 89.04, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 129.65, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 122.31, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 143.51, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 94.59, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 89.04, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Fistula repair transperine", "code_information": [ { "code": "57308", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 20990.48, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 38087.64, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 38087.64, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Fixation of knee joint", "code_information": [ { "code": "27570", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1179.66, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 873.82, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 6119.4, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 11103.75, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1179.66, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 11103.75, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "FLAVOCOXID 500 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68040060216", "type": "NDC" } ], "standard_charges": [ { "minimum": 9.85, "maximum": 32.85, "gross_charge": 34.95, "discounted_cash": 19.22, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.27, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.08, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.96, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.6, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.17, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.78, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.94, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.9, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.85, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.76, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.85, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.71, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.21, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.31, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.77, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.85, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.37, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.08, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.79, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.21, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.76, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.27, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.08, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "FLECAINIDE ACETATE 100 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "50268032115", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "FLECAINIDE ACETATE 150 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00054001221", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "FLECAINIDE ACETATE 50 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00054001020", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "FLECAINIDE ACETATE 50 MG/ML SUSPENSION", "drug_information": { "unit": "2.000000", "type": "UN" }, "code_information": [ { "code": "R0054001125", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "FLEET ENEMA 7-19 GM/118ML RE ENEM", "drug_information": { "unit": "133.000000", "type": "UN" }, "code_information": [ { "code": "00536741551_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "FLEET PEDIATRIC 3.5-9.5 GM/59ML RE ENEM", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00132020220", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": 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total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", 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"additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "FLINTSTONES COMPLETE PO CHEW", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "1650008806", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "FLORANEX PO PACK", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "64980014612", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "FLORBETAPIR F 18 500-1900 MBQ/ML IV SOLN", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00002120001", "type": "NDC" } ], "standard_charges": [ { "minimum": 1198.26, "maximum": 8541.78, "gross_charge": 9087.0, "discounted_cash": 4997.85, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5270.46, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1198.26, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7269.6, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7696.69, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2644.32, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4361.76, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5443.11, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 5434.03, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8541.78, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7996.56, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2560.72, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7723.95, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6815.25, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3201.35, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6179.16, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 8541.78, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7115.12, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1617.65, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7224.17, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6815.25, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7996.56, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5270.46, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1198.26, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "FLORTAUCIPIR F 18 300-1900 MBQ/ML IV SOLN", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00002121001", "type": "NDC" } ], "standard_charges": [ { "minimum": 2025.66, "maximum": 7590.03, "gross_charge": 8074.5, "discounted_cash": 4440.98, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4683.21, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2025.66, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6459.6, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6839.1, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2349.68, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3875.76, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4836.63, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": 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"methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6055.88, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2844.65, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5490.66, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7590.03, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6322.33, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2734.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6419.23, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6055.88, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7105.56, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4683.21, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2025.66, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "FLORTAUCIPIR F 18 300-3700 MBQ/ML IV SOLN", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00002122001", "type": "NDC" } ], "standard_charges": [ { "minimum": 2025.66, "maximum": 10857.0, "gross_charge": 11550.0, "discounted_cash": 6352.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 6699.0, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2025.66, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9240.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9782.85, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3361.05, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5544.0, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6918.45, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 6906.9, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10857.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10164.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3254.79, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9817.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8662.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 4069.07, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7854.0, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 10857.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 9043.65, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2734.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 9182.25, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8662.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10164.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6699.0, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2025.66, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "FLOTUFOLASTAT F 18 GALLIUM 296-5846 MBQ/ML IV SOLN", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "69932000201", "type": "NDC" } ], "standard_charges": [ { "minimum": 4282.63, "maximum": 14285.56, "gross_charge": 15197.4, "discounted_cash": 8358.57, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 8814.49, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 8297.78, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12157.92, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12872.2, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4422.44, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7294.75, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 9103.24, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 9088.05, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14285.56, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13373.71, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 4282.63, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12917.79, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11398.05, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 5354.04, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 10334.23, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 14285.56, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 11899.56, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8297.78, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 12081.93, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11398.05, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13373.71, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8814.49, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8297.78, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "FLUCICLOVINE F 18 9-221 MCI/ML IV SOLN", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "69932000101", "type": "NDC" } ], "standard_charges": [ { "minimum": 146.56, "maximum": 13942.08, "gross_charge": 14832.0, "discounted_cash": 8157.6, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 8602.56, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 146.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11865.6, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12562.7, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4316.11, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7119.36, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 8884.37, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 8869.54, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13942.08, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13052.16, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 4179.66, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12607.2, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11124.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 5225.31, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 10085.76, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 13942.08, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 11613.46, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 197.85, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 11791.44, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11124.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13052.16, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8602.56, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 146.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "FLUCONAZOLE 10 MG/ML PO SUSR", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "57237014935", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.54, "maximum": 5.14, "gross_charge": 5.47, "discounted_cash": 3.01, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.17, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.99, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.38, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.63, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.59, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.63, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.28, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.27, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.14, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.81, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.54, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.65, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.1, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.93, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.14, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.28, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.99, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.35, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.1, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.81, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.17, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.99, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "FLUCONAZOLE 100 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "50268033715", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "FLUCONAZOLE 150 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68001025317", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "FLUCONAZOLE 2 MG/ML IV LOADING DOSE FROM RTU (NICU)", "drug_information": { "unit": "100.000000", "type": "UN" }, "code_information": [ { "code": "25021018482", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "FLUCONAZOLE 2 MG/ML IV MAINTENANCE DOSE FROM RTU (NICU)", "drug_information": { "unit": "100.000000", "type": "UN" }, "code_information": [ { "code": "25021018482_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "FLUCONAZOLE 2 MG/ML IVPB FROM NS RTU (1-200 MG)", "drug_information": { "unit": "100.000000", "type": "UN" }, "code_information": [ { "code": "25021018482_3", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "FLUCONAZOLE 2 MG/ML IVPB FROM NS RTU (1001-1200 MG)", "drug_information": { "unit": "100.000000", "type": "UN" }, "code_information": [ { "code": "25021018482_4", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "FLUCONAZOLE 2 MG/ML IVPB FROM NS RTU (1201-1400 MG)", "drug_information": { "unit": "100.000000", "type": "UN" }, "code_information": [ { "code": "25021018482_5", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "FLUCONAZOLE 2 MG/ML IVPB FROM NS RTU (1401-1600 MG)", "drug_information": { "unit": "100.000000", "type": "UN" }, "code_information": [ { "code": "25021018482_6", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "FLUCONAZOLE 2 MG/ML IVPB FROM NS RTU (1601-1800 MG)", "drug_information": { "unit": "100.000000", "type": "UN" }, "code_information": [ { "code": "25021018482_7", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "FLUCONAZOLE 2 MG/ML IVPB FROM NS RTU (1801-2000 MG)", "drug_information": { "unit": "100.000000", "type": "UN" }, "code_information": [ { "code": "25021018482_8", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "FLUCONAZOLE 2 MG/ML IVPB FROM NS RTU (201-400 MG)", "drug_information": { "unit": "100.000000", "type": "UN" }, "code_information": [ { "code": "25021018482_9", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "FLUCONAZOLE 2 MG/ML IVPB FROM NS RTU (401-600 MG)", "drug_information": { "unit": "100.000000", "type": "UN" }, "code_information": [ { "code": "25021018482_10", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "FLUCONAZOLE 2 MG/ML IVPB FROM NS RTU (601-800 MG)", "drug_information": { "unit": "100.000000", "type": "UN" }, "code_information": [ { "code": "25021018482_11", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "FLUCONAZOLE 2 MG/ML IVPB FROM NS RTU (801-1000 MG)", "drug_information": { "unit": "100.000000", "type": "UN" }, "code_information": [ { "code": "25021018482_12", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "FLUCONAZOLE 2 MG/ML SYR FROM NS RTU", "drug_information": { "unit": "100.000000", "type": "UN" }, "code_information": [ { "code": "25021018482_13", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "FLUCONAZOLE 200 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "50268033915", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "FLUCONAZOLE 200 MG/100 ML NS RTU", "drug_information": { "unit": "100.000000", "type": "UN" }, "code_information": [ { "code": "25021018482_14", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "FLUCONAZOLE 40 MG/ML PO SUSR", "drug_information": { "unit": "35.000000", "type": "UN" }, "code_information": [ { "code": "57237015035", "type": "NDC" } ], "standard_charges": [ { "minimum": 13.21, "maximum": 44.07, "gross_charge": 46.88, "discounted_cash": 25.78, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.19, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.6, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.5, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.71, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.5, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.08, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.03, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 44.07, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.25, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.21, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.85, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.16, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.52, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.88, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 44.07, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.71, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.6, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.27, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.16, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.25, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.19, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.6, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "FLUCONAZOLE 40 MG/ML PO SUSR (NICU)", "drug_information": { "unit": "35.000000", "type": "UN" }, "code_information": [ { "code": "57237015035_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 13.21, "maximum": 44.07, "gross_charge": 46.88, "discounted_cash": 25.78, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.19, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.6, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.5, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.71, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.5, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.08, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.03, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 44.07, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.25, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.21, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.85, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.16, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.52, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.88, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 44.07, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.71, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.6, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.27, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.16, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.25, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.19, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.6, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "FLUCONAZOLE 400 MG/200 ML NS RTU", "drug_information": { "unit": "200.000000", "type": "UN" }, "code_information": [ { "code": "25021018487", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "FLUCYTOSINE 250 MG PO CAPS", "drug_information": { "unit": "2.000000", "type": "UN" }, "code_information": [ { "code": "60687059921", "type": "NDC" } ], "standard_charges": [ { "minimum": 64.94, "maximum": 216.61, "gross_charge": 230.44, "discounted_cash": 126.74, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 133.66, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 125.82, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 184.35, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 195.18, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 67.06, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 110.61, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 138.03, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 137.8, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 216.61, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 202.79, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 64.94, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 195.87, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 172.83, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 81.18, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 156.7, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 216.61, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 180.43, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 125.82, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 183.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 172.83, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 202.79, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 133.66, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 125.82, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "FLUCYTOSINE 500 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "59651033201", "type": "NDC" } ], "standard_charges": [ { "minimum": 8.59, "maximum": 28.67, "gross_charge": 30.5, "discounted_cash": 16.78, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.69, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.65, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.4, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.83, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.88, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.64, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.27, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.24, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.67, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.84, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.59, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.93, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.88, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.74, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.67, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.88, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.65, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.25, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.88, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.84, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.69, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.65, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "FLUCYTOSINE 50MG/ML SUSPENSION", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "08252000025", "type": "NDC" } ], "standard_charges": [ { "minimum": 21.98, "maximum": 73.32, "gross_charge": 78.0, "discounted_cash": 42.9, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.24, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.59, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 62.4, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 66.07, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.7, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.44, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.72, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.64, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 73.32, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 68.64, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.98, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 66.3, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 58.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.48, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 53.04, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 73.32, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.07, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.59, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 62.01, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 58.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 68.64, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.24, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.59, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "FLUDARABINE PHOSPHATE 50 MG/2ML IV SOLN", "drug_information": { "unit": "2.000000", "type": "UN" }, "code_information": [ { "code": "63323019202", "type": "NDC" } ], "standard_charges": [ { "minimum": 26.37, "maximum": 98.88, "gross_charge": 93.58, "discounted_cash": 51.47, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.28, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 73.25, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.86, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 79.26, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.23, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 44.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 56.05, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.97, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.35, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.37, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 79.54, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 70.19, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.97, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.63, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.97, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 73.27, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 98.88, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.4, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 70.19, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.35, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.28, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 73.25, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "FLUDROCORTISONE ACETATE 0.05 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "4229152901", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed 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"standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "FLUDROCORTISONE ACETATE 0.1 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "50268033015", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", 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}, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of 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charges" } ], "additional_generic_notes": "" } ] }, { "description": "FLUMAZENIL 0.5 MG/5ML IV SOLN -CODE USE PEDS", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "36000014810", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 1158.0, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, 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"standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", 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"methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "FLUMAZENIL 1 MG/10ML IV SOLN", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "00143978310", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 1158.0, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.72, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", 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"plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "FLUNISOLIDE 25 MCG/ACT (0.025%) NA SOLN", "drug_information": { "unit": "25.000000", "type": "UN" }, "code_information": [ { "code": "24208034425", "type": "NDC" } ], "standard_charges": [ { "minimum": 30.91, "maximum": 103.12, "gross_charge": 109.7, "discounted_cash": 60.34, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.63, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.9, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.76, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 92.92, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.92, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC 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charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.91, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.25, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.28, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.65, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", 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"methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.67, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.69, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.7, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 79.69, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.61, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.89, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 72.06, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.59, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.87, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 57.65, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 79.69, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 66.38, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.29, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 67.4, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.59, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.61, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.17, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.29, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "FLUOCINOLONE ACETONIDE 0.01 % EX SOLN", "drug_information": { "unit": "60.000000", "type": "UN" }, "code_information": [ { "code": "21922000301", "type": "NDC" } ], "standard_charges": [ { "minimum": 10.5, "maximum": 35.02, "gross_charge": 37.25, "discounted_cash": 20.49, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.61, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.34, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.55, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.84, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.88, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.31, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.28, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.02, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.78, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.5, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.66, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.94, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.12, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.33, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.02, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.17, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.34, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.61, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.94, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.78, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.61, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.34, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "FLUOCINOLONE ACETONIDE 0.01 % OT OIL", "drug_information": { "unit": "20.000000", "type": "UN" }, "code_information": [ { "code": "68791010320", "type": "NDC" } ], "standard_charges": [ { "minimum": 17.09, "maximum": 57.01, "gross_charge": 60.65, "discounted_cash": 33.36, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.18, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.11, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 48.52, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 51.37, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.65, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.11, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.33, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.27, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 57.01, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 53.37, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.09, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 51.55, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.49, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.37, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.24, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue 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billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 53.37, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.18, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.11, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "FLUOCINOLONE ACETONIDE 0.025 % EX OINT", "drug_information": { "unit": "15.000000", "type": "GR" }, "code_information": [ { "code": "00713022415", "type": "NDC" } ], "standard_charges": [ { "minimum": 10.0, "maximum": 33.37, "gross_charge": 35.5, "discounted_cash": 19.53, "setting": 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"additional_payer_notes": "N/A", "standard_charge_dollar": 31.24, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.18, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.63, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.51, "standard_charge_percentage": 35.0, 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"standard_charge_dollar": 28.22, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.63, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.24, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.59, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.38, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "FLUOCINOLONE ACETONIDE 0.18 MG IZ IMPL", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "71879013601", "type": "NDC" } ], "standard_charges": [ { "minimum": 7605.22, "maximum": 25368.72, "gross_charge": 26988.0, "discounted_cash": 14843.4, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 15653.04, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 14735.45, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21590.4, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 22858.84, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7853.51, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12954.24, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 16165.81, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 11394.0, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 25368.72, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23749.44, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 7605.22, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 22939.8, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20241.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 9507.87, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 18351.84, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 25368.72, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21131.6, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 14735.45, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 15189.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20241.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23749.44, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 15653.04, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 14735.45, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "FLUOCINOLONE ACETONIDE 0.19 MG IZ IMPL", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68611019002", "type": "NDC" } ], "standard_charges": [ { "minimum": 270.48, "maximum": 25098.0, "gross_charge": 26700.0, "discounted_cash": 14685.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 15486.0, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 270.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21360.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 22614.9, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7769.7, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12816.0, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 15993.3, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 11394.0, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 25098.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23496.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 7524.06, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 22695.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20025.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 9406.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 18156.0, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 25098.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 20906.1, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 365.14, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 15189.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20025.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23496.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 15486.0, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 270.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "FLUOCINOLONE ACETONIDE 0.59 MG IZ IMPL", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "24208041601", "type": "NDC" } ], "standard_charges": [ { "minimum": 182.08, "maximum": 53650.5, "gross_charge": 57075.0, "discounted_cash": 31391.25, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 33103.5, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 182.08, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 45660.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 48342.53, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16608.83, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 27396.0, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 34187.93, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 11394.0, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 53650.5, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 50226.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 16083.74, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 48513.75, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42806.25, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 20107.52, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 38811.0, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 53650.5, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 44689.73, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 245.81, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 15189.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42806.25, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 50226.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 33103.5, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 182.08, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "FLUOCINOLONE ACETONIDE BODY 0.01 % EX OIL", "drug_information": { "unit": "119.000000", "type": "UN" }, "code_information": [ { "code": "68791010104", "type": "NDC" } ], "standard_charges": [ { "minimum": 44.47, "maximum": 148.33, "gross_charge": 157.8, "discounted_cash": 86.79, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 91.52, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.16, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 126.24, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 133.66, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.92, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.74, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 94.52, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 94.36, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 148.33, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 138.86, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 44.47, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 134.13, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 118.35, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.59, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 107.3, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 148.33, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 123.56, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.16, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 125.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 118.35, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 138.86, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 91.52, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.16, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "FLUOCINOLONE ACETONIDE SCALP 0.01 % EX OIL", "drug_information": { "unit": "119.000000", "type": "UN" }, "code_information": [ { "code": "68791010204", "type": "NDC" } ], "standard_charges": [ { "minimum": 21.28, "maximum": 71.0, "gross_charge": 75.53, "discounted_cash": 41.54, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.81, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.24, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.42, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.97, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.98, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.25, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.24, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.17, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 71.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 66.47, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.28, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 64.2, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 56.65, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.61, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 51.36, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 71.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.14, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.24, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.05, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 56.65, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 66.47, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.81, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.24, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "FLUOCINONIDE 0.05 % EX CREA", "drug_information": { "unit": "15.000000", "type": "GR" }, "code_information": [ { "code": "00093026215", "type": "NDC" } ], "standard_charges": [ { "minimum": 4.76, "maximum": 15.87, "gross_charge": 16.88, "discounted_cash": 9.28, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.79, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.5, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.3, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.91, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.1, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.11, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.09, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.87, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.85, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.76, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.35, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.66, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.95, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.48, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.87, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.22, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.42, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.66, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.85, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.79, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "FLUOCINONIDE 0.05 % EX GEL", "drug_information": { "unit": "15.000000", "type": "GR" }, "code_information": [ { "code": "51672127901", "type": "NDC" } ], "standard_charges": [ { "minimum": 9.45, "maximum": 31.54, "gross_charge": 33.55, "discounted_cash": 18.45, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.46, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.32, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.84, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.42, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.76, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.1, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.1, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.06, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.54, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.45, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.52, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.16, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.82, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.81, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.54, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.27, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.32, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.67, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.16, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.46, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.32, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "FLUOCINONIDE 0.05 % EX OINT", "drug_information": { "unit": "15.000000", "type": "GR" }, "code_information": [ { "code": "51672126401", "type": "NDC" } ], "standard_charges": [ { "minimum": 6.96, "maximum": 23.22, "gross_charge": 24.7, "discounted_cash": 13.59, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.33, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.49, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.76, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.92, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.19, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.86, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.8, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.77, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.22, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.74, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.96, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.53, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.7, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.22, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.34, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.49, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.64, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.53, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.74, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.33, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.49, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "FLUOCINONIDE 0.05 % EX SOLN", "drug_information": { "unit": "60.000000", "type": "UN" }, "code_information": [ { "code": "21922000101", "type": "NDC" } ], "standard_charges": [ { "minimum": 10.97, "maximum": 36.59, "gross_charge": 38.93, "discounted_cash": 21.41, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.58, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.26, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.14, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.97, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.33, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.69, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.32, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.28, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.59, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.26, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.97, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.09, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.2, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.72, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.47, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.59, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.48, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.26, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.95, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.2, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.26, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.58, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.26, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "FLUOCINONIDE EMULSIFIED BASE 0.05 % EX CREA", "drug_information": { "unit": "15.000000", "type": "GR" }, "code_information": [ { "code": "00093026315", "type": "NDC" } ], "standard_charges": [ { "minimum": 24.59, "maximum": 82.02, "gross_charge": 87.25, "discounted_cash": 47.99, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.61, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.64, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 69.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 73.9, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.39, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.88, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.26, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.18, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.02, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 76.78, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.59, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.16, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.44, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.74, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.33, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.02, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 68.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.64, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 69.36, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.44, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 76.78, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.61, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.64, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "FLUORESCEIN SODIUM 1 MG OP STRP", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "17238090011", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "FLUORESCEIN SODIUM 10 % IV SOLN", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "00065009265", "type": "NDC" } ], "standard_charges": [ { "minimum": 33.27, "maximum": 1158.0, "gross_charge": 118.08, "discounted_cash": 64.94, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 68.49, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 64.47, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 102.49, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.36, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 56.68, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 70.73, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 70.61, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 111.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.91, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 100.37, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.56, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.6, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 80.29, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 111.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 92.46, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 64.47, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.87, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.56, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.91, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 68.49, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 64.47, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Fluoro exam of g/colon tube", "code_information": [ { "code": "49465", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 178.17, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 131.98, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 446.4, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 810.01, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 178.17, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 810.01, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "FLUOROESTRADIOL F 18 4-100 MCI/ML IV SOLN", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "72874000101", "type": "NDC" } ], "standard_charges": [ { "minimum": 272.27, "maximum": 13070.78, "gross_charge": 13905.09, "discounted_cash": 7647.8, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 8064.95, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 272.27, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11124.07, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11777.61, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4046.38, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6674.44, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 8329.15, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 8315.24, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13070.78, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12236.48, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3918.45, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11819.33, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10428.82, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 4898.76, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 9455.46, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 13070.78, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 10887.69, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 367.57, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 11054.55, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10428.82, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12236.48, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8064.95, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 272.27, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "FLUOROMETHOLONE 0.1 % OP SUSP", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "60758088005", "type": "NDC" } ], "standard_charges": [ { "minimum": 50.96, "maximum": 169.99, "gross_charge": 180.84, "discounted_cash": 99.46, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 104.89, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 98.74, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 144.67, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 153.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.62, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 108.32, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 108.14, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 169.99, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 159.14, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.96, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 153.71, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 135.63, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.71, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 122.97, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 169.99, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 141.6, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 98.74, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 143.77, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 135.63, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 159.14, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 104.89, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 98.74, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "FLUOROMETHOLONE ACETATE 0.1 % OP SUSP", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "00065009605", "type": "NDC" } ], "standard_charges": [ { "minimum": 68.78, "maximum": 229.44, "gross_charge": 244.08, "discounted_cash": 134.24, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 141.57, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 133.27, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 195.26, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 206.74, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 71.03, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 117.16, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 146.2, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 145.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 229.44, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 214.79, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 68.78, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 207.47, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 183.06, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 85.99, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 165.97, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 229.44, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 191.11, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 133.27, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 194.04, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 183.06, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 214.79, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 141.57, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 133.27, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "FLUOROURACIL 1 GM/20ML IV SOLN", "drug_information": { "unit": "20.000000", "type": "UN" }, "code_information": [ { "code": "63323011720", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "FLUOROURACIL 2.5 GM/50ML IV SOLN", "drug_information": { "unit": "50.000000", "type": "UN" }, "code_information": [ { "code": "63323011751", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "FLUOROURACIL 5 % EX CREA", "drug_information": { "unit": "40.000000", "type": "GR" }, "code_information": [ { "code": "51672411806", "type": "NDC" } ], "standard_charges": [ { "minimum": 14.86, "maximum": 49.59, "gross_charge": 52.75, "discounted_cash": 29.01, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.8, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 44.68, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.35, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.32, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.6, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.54, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.59, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.42, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.86, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 44.84, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.56, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.58, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.87, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.59, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.3, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.8, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.94, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.56, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.42, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.8, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "FLUOROURACIL 5 GM/100ML IV SOLN", "drug_information": { "unit": "100.000000", "type": "UN" }, "code_information": [ { "code": "63323011761", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "FLUOROURACIL 5 MG/0.1 ML SUBCONJUNCTIVAL SYRINGE", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "63323011710_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "FLUOROURACIL 50 MG/ML TOPICAL SYRINGE (OPH)", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "C6332311710", "type": "NDC" } ], "standard_charges": [ { "minimum": 15.84, "maximum": 52.83, "gross_charge": 56.2, "discounted_cash": 30.91, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.69, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 44.96, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.6, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.35, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.98, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.66, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.61, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.83, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.46, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.84, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.77, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.15, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.8, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.83, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 44.0, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.69, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 44.68, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.15, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.46, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.69, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "FLUOROURACIL 500 MG/10ML IV SOLN", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "63323011710", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "FLUOROURACIL CHEMO SYRINGE", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "63323011710_3", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "FLUOXETINE HCL 10 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "1671435101", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "FLUOXETINE HCL 20 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00904734661", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "FLUOXETINE HCL 40 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687065901", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "FLUPHENAZINE DECANOATE 25 MG/ML IJ SOLN", "drug_information": { "unit": "0.500000", "type": "UN" }, "code_information": [ { "code": "63323027205", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "FLUPHENAZINE HCL 1 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00527178801", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "FLUPHENAZINE HCL 10 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00527179101", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.52, "maximum": 8.42, "gross_charge": 8.96, "discounted_cash": 4.93, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.89, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.17, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.59, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.61, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.3, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.37, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.36, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.42, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.88, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.52, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.62, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.72, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.16, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.09, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.42, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.02, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.89, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.12, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.72, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.88, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.89, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "FLUPHENAZINE HCL 2.5 MG/ML IJ SOLN", "drug_information": { "unit": "0.500000", "type": "UN" }, "code_information": [ { "code": "63323028110", "type": "NDC" } ], "standard_charges": [ { "minimum": 4.01, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.01, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.42, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.01, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "FLUPHENAZINE HCL 5 MG/ML PO CONC", "drug_information": { "unit": "0.200000", "type": "UN" }, "code_information": [ { "code": "00121065304", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "FLURBIPROFEN 100 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00093071101", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "FLUTEMETAMOL F 18 4.05 MCI/ML IV SOLN", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "17156006730", "type": "NDC" } ], "standard_charges": [ { "minimum": 477.42, "maximum": 8178.0, "gross_charge": 8700.0, "discounted_cash": 4785.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5046.0, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 477.42, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6960.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7368.9, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2531.7, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4176.0, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5211.3, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 5202.6, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8178.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7656.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2451.66, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7395.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6525.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3065.01, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5916.0, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 8178.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6812.1, "standard_charge_percentage": 78.0, "methodology": 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"standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 477.42, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "FLUTICASONE FUROATE 200 MCG/ACT IN AEPB", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00173087614", "type": "NDC" } ], "standard_charges": [ { "minimum": 59.35, "maximum": 197.96, "gross_charge": 210.6, "discounted_cash": 115.83, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 122.15, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 114.99, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 168.48, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 178.38, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.28, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 101.09, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": 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billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 179.01, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 157.95, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.19, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 143.21, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 197.96, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 164.9, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 114.99, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 167.43, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 157.95, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 185.33, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 122.15, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 114.99, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "FLUTICASONE FUROATE-VILANTEROL 100-25 MCG/ACT IN AEPB", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00173085914", "type": "NDC" } ], "standard_charges": [ { "minimum": 40.69, "maximum": 135.75, "gross_charge": 144.41, "discounted_cash": 79.43, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 83.76, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 78.85, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 115.53, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 122.32, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.02, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 69.32, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.5, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.36, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 135.75, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 127.08, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.69, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 122.75, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 108.31, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.88, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 98.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 135.75, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 113.07, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 78.85, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 114.81, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 108.31, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 127.08, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 83.76, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 78.85, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "FLUTICASONE FUROATE-VILANTEROL 200-25 MCG/ACT IN AEPB", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00173088214", "type": "NDC" } ], "standard_charges": [ { "minimum": 40.69, "maximum": 135.75, "gross_charge": 144.41, "discounted_cash": 79.43, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 83.76, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 78.85, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 115.53, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 122.32, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.02, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 69.32, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.5, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.36, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 135.75, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 127.08, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.69, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 122.75, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 108.31, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.88, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 98.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 135.75, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 113.07, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 78.85, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 114.81, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 108.31, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 127.08, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 83.76, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 78.85, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "FLUTICASONE PROPIONATE 0.005 % EX OINT", "drug_information": { "unit": "60.000000", "type": "GR" }, "code_information": [ { "code": "45802022137", "type": "NDC" } ], "standard_charges": [ { "minimum": 22.43, "maximum": 74.82, "gross_charge": 79.6, "discounted_cash": 43.78, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.17, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.46, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.68, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 67.42, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.21, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.68, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.6, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.82, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 70.05, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.43, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 67.66, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.7, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.04, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.13, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.82, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 62.33, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.46, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.28, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.7, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 70.05, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.17, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.46, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "FLUTICASONE PROPIONATE 0.05 % EX CREA", "drug_information": { "unit": "30.000000", "type": "GR" }, "code_information": [ { "code": "00168033230", "type": "NDC" } ], "standard_charges": [ { "minimum": 15.61, "maximum": 52.06, "gross_charge": 55.38, "discounted_cash": 30.46, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.12, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.24, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 44.3, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.91, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.12, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.58, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.17, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.12, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.06, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 48.73, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.61, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.07, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.54, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.51, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.66, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.06, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.36, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.24, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 44.03, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.54, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 48.73, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.12, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.24, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "FLUTICASONE PROPIONATE 50 MCG/ACT NA SUSP", "drug_information": { "unit": "16.000000", "type": "GR" }, "code_information": [ { "code": "60505082901", "type": "NDC" } ], "standard_charges": [ { "minimum": 4.74, "maximum": 15.82, "gross_charge": 16.83, "discounted_cash": 9.26, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.76, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.19, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.46, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.26, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.9, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.08, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.08, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.06, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.82, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.81, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.74, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.31, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.62, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.93, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.44, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.82, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.18, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.19, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.38, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.62, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.81, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.76, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.19, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "FLUTICASONE PROPIONATE HFA 110 MCG/ACT IN AERO", "drug_information": { "unit": "12.000000", "type": "GR" }, "code_information": [ { "code": "66993007996", "type": "NDC" } ], "standard_charges": [ { "minimum": 97.62, "maximum": 325.62, "gross_charge": 346.4, "discounted_cash": 190.52, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 200.91, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 189.13, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 277.12, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 293.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 100.8, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 166.27, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 207.49, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 207.15, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 325.62, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 304.83, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 97.62, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 294.44, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 259.8, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 122.04, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 235.55, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 325.62, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 271.23, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 189.13, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 275.39, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 259.8, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 304.83, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 200.91, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 189.13, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "FLUTICASONE PROPIONATE HFA 220 MCG/ACT IN AERO", "drug_information": { "unit": "12.000000", "type": "GR" }, "code_information": [ { "code": "66993008096", "type": "NDC" } ], "standard_charges": [ { "minimum": 151.62, "maximum": 505.77, "gross_charge": 538.05, "discounted_cash": 295.93, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 312.07, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 293.78, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 430.44, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 455.73, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 156.57, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 258.26, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 322.29, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 321.75, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 505.77, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 473.48, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 151.62, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 457.34, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 403.54, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 189.56, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 365.87, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 505.77, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 421.29, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 293.78, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 427.75, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 403.54, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 473.48, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 312.07, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 293.78, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "FLUTICASONE PROPIONATE HFA 44 MCG/ACT IN AERO", "drug_information": { "unit": "11.000000", "type": "GR" }, "code_information": [ { "code": "66993007896", "type": "NDC" } ], "standard_charges": [ { "minimum": 145.83, "maximum": 486.45, "gross_charge": 517.5, "discounted_cash": 284.63, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 300.15, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 282.56, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 414.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 438.32, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 150.59, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 248.4, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 309.98, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 309.47, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 486.45, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 455.4, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 145.83, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 439.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 388.13, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 182.32, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 351.9, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 486.45, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 405.2, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 282.56, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 411.41, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 388.13, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 455.4, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 300.15, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 282.56, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "FLUTICASONE-SALMETEROL 100-50 MCG/ACT IN AEPB", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00054032656", "type": "NDC" } ], "standard_charges": [ { "minimum": 50.72, "maximum": 169.2, "gross_charge": 180.0, "discounted_cash": 99.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 104.4, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 98.28, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 144.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 152.46, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.38, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.4, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 107.82, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 107.64, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 169.2, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 158.4, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.72, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 153.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 135.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 122.4, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 169.2, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 140.94, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 98.28, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 143.1, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 135.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 158.4, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 104.4, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 98.28, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "FLUTICASONE-SALMETEROL 250-50 MCG/ACT IN AEPB", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00054032756", "type": "NDC" } ], "standard_charges": [ { "minimum": 60.36, "maximum": 201.35, "gross_charge": 214.2, "discounted_cash": 117.81, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 124.24, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 116.95, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 171.36, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 181.43, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 62.33, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 102.82, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 128.31, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 128.09, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 201.35, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 188.5, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.36, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 182.07, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 160.65, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.46, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 145.66, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 201.35, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 167.72, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 116.95, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 170.29, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 160.65, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 188.5, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 124.24, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 116.95, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "FLUTICASONE-SALMETEROL 500-50 MCG/ACT IN AEPB", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "66993058697", "type": "NDC" } ], "standard_charges": [ { "minimum": 78.66, "maximum": 262.4, "gross_charge": 279.15, "discounted_cash": 153.53, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 161.91, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 152.42, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 223.32, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 236.44, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 81.23, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 133.99, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 167.21, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 166.93, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 262.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 245.65, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 78.66, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 237.28, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 209.36, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 98.34, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 189.82, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 262.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 218.57, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 152.42, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 221.92, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 209.36, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 245.65, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 161.91, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 152.42, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "FLUVASTATIN SODIUM 40 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00378802193", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.79, "maximum": 5.97, "gross_charge": 6.35, "discounted_cash": 3.49, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.68, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.47, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.08, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.38, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.85, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.05, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.8, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.8, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.97, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.59, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.79, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.76, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.24, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.32, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.97, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.97, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.47, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.05, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.76, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.59, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.68, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.47, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "FLUVOXAMINE MALEATE 100 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "R6255916001", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "FLUVOXAMINE MALEATE 25 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "3535602930", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "FLUVOXAMINE MALEATE 50 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "R6255915901", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "FLUVOXAMINE MALEATE ER 150 MG PO CP24", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00228284903", "type": "NDC" } ], "standard_charges": [ { "minimum": 3.82, "maximum": 12.74, "gross_charge": 13.55, "discounted_cash": 7.45, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.86, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.4, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.84, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.48, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.94, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.5, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.12, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.1, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.74, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.92, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.82, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.52, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.16, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.77, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.21, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.74, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.61, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.4, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.77, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.16, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.92, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.86, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.4, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "FMT CAPSULE G3", "drug_information": { "unit": "30.000000", "type": "UN" }, "code_information": [ { "code": "08252000139", "type": "NDC" } ], "standard_charges": [ { "minimum": 1158.0, "maximum": 5499.0, "gross_charge": 5850.0, "discounted_cash": 3217.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3393.0, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3194.1, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5077.8, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1702.35, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2808.0, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3504.15, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 3498.3, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5499.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5148.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1648.53, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4972.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4387.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2060.96, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3978.0, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5499.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4580.55, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3194.1, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4650.75, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4387.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5148.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3393.0, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3194.1, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "FMT250 250 ML ENEMA", "drug_information": { "unit": "250.000000", "type": "UN" }, "code_information": [ { "code": "08252000140", "type": "NDC" } ], "standard_charges": [ { "minimum": 1123.68, "maximum": 3748.25, "gross_charge": 3987.5, "discounted_cash": 2193.13, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2312.75, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2177.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3461.15, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1160.36, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1914.0, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2388.51, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2384.53, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3748.25, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3509.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1123.68, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3389.38, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2990.63, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1404.8, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2711.5, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3748.25, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3122.21, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2177.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3170.06, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2990.63, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3509.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2312.75, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2177.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "FMT30 30 ML NASOGASTRIC", "drug_information": { "unit": "30.000000", "type": "UN" }, "code_information": [ { "code": "08252000030", "type": "NDC" } ], "standard_charges": [ { "minimum": 1158.0, "maximum": 4497.9, "gross_charge": 4785.0, "discounted_cash": 2631.75, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2775.3, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2612.61, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4153.38, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1392.44, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2296.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2866.22, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2861.43, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4497.9, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4210.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1348.41, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4067.25, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3588.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1685.76, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3253.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4497.9, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3746.66, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2612.61, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3804.08, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3588.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4210.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2775.3, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2612.61, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Fna bx w/ct gdn 1st les", "code_information": [ { "code": "10009", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 518.62, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 384.16, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 3558.3, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 6456.61, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 518.62, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 6456.61, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Fna bx w/fluor gdn 1st les", "code_information": [ { "code": "10007", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 518.62, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 384.16, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 2782.55, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 5049.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 518.62, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 5049.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Fna bx w/o img gdn 1st les", "code_information": [ { "code": "10021", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 294.49, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 218.14, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 13863.98, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 25300.45, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 294.49, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 25300.45, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Fna bx w/us gdn 1st les", "code_information": [ { "code": "10005", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 518.62, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 384.16, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 1805.44, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 3276.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 518.62, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 3276.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "FOLIC ACID 1 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687068101", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "FOLIC ACID 1 MG/ML ORAL SOLUTION", "drug_information": { "unit": "200.000000", "type": "UN" }, "code_information": [ { "code": "P0143971710", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.41, "maximum": 1158.0, "gross_charge": 5.0, "discounted_cash": 2.75, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.9, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.73, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.34, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.46, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.99, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.7, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.4, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.25, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.76, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.7, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.92, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.73, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.98, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.4, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.9, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.73, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "FOLIC ACID 400 MCG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "50268034615", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", 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"additional_payer_notes": "N/A", "standard_charge_dollar": 490.33, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 770.75, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 721.56, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 231.06, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 696.96, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 614.96, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 288.87, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 557.57, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 770.75, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 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"standard_charge_percentage": 48.0, "estimated_amount": 6742.59, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 12234.56, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1719.62, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 12234.56, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "FOMEPIZOLE 1.5 GM/1.5ML IV SOLN", "drug_information": { "unit": "1.500000", "type": "UN" }, "code_information": [ { "code": "70710147801", "type": "NDC" } ], "standard_charges": [ { "minimum": 3.52, "maximum": 1753.81, "gross_charge": 1865.76, "discounted_cash": 1026.17, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1082.14, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1492.61, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1580.3, "standard_charge_percentage": 85.0, "methodology": 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"standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1641.87, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 525.77, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1585.9, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1399.32, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 657.31, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1268.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1753.81, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1460.89, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.75, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1483.28, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1399.32, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1641.87, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1082.14, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "FONDAPARINUX 12.5 MG/ML SC SOLN CUSTOM SYRINGE", "drug_information": { "unit": "1.600000", "type": "UN" }, "code_information": [ { "code": "70710151706", "type": "NDC" } ], "standard_charges": [ { "minimum": 98.84, "maximum": 329.69, "gross_charge": 350.73, "discounted_cash": 192.9, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 203.42, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 191.5, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 280.58, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 297.07, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 102.06, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 168.35, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 210.09, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 209.74, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 329.69, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 308.64, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 98.84, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 298.12, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 263.05, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 123.56, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 238.5, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 329.69, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 274.62, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 191.5, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 278.83, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 263.05, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 308.64, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 203.42, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 191.5, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "FONDAPARINUX 5 MG/ML SC SOLN CUSTOM SYRINGE", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00781344395", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "FONDAPARINUX SODIUM 10 MG/0.8ML SC SOLN", "drug_information": { "unit": "0.800000", "type": "UN" }, "code_information": [ { "code": "55111068110", "type": "NDC" } ], "standard_charges": [ { "minimum": 42.34, "maximum": 141.24, "gross_charge": 150.26, "discounted_cash": 82.64, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.15, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.04, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 120.21, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 127.27, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.73, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 72.12, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 90.01, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 89.86, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 141.24, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 132.23, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.34, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 127.72, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 112.7, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.94, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 102.18, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 141.24, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 117.65, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.04, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 119.46, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 112.7, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 132.23, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.15, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.04, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "FONDAPARINUX SODIUM 2.5 MG/0.5ML SC SOLN", "drug_information": { "unit": "0.500000", "type": "UN" }, "code_information": [ { "code": "00781344395_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "FONDAPARINUX SODIUM 5 MG/0.4ML SC SOLN", "drug_information": { "unit": "0.400000", "type": "UN" }, "code_information": [ { "code": "55111067910", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "FONDAPARINUX SODIUM 7.5 MG/0.6ML SC SOLN", "drug_information": { "unit": "0.600000", "type": "UN" }, "code_information": [ { "code": "67457058406", "type": "NDC" } ], "standard_charges": [ { "minimum": 20.43, "maximum": 68.16, "gross_charge": 72.51, "discounted_cash": 39.88, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.06, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.59, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 58.01, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.42, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.1, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.43, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.36, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 68.16, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.81, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.43, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.63, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.38, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.55, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.31, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 68.16, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 56.78, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.59, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 57.65, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.38, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.81, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.06, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.59, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Forehead flap w/vasc pedicle", "code_information": [ { "code": "15731", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2698.5, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1998.89, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 12777.42, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 23302.04, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2698.5, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 23302.04, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "FORMALIN 10% ACETATE BUFFERED SOLUTION", "drug_information": { "unit": "250.000000", "type": "UN" }, "code_information": [ { "code": "P6076000025", "type": "NDC" } ], "standard_charges": [ { "minimum": 4.4, "maximum": 1158.0, "gross_charge": 15.63, "discounted_cash": 8.6, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.07, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.53, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.57, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.55, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.5, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.36, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.35, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.69, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.75, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.4, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.29, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.72, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.51, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.63, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.69, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.24, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.53, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.43, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.72, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.75, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.07, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.53, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "FORMALIN 3% ACETATE BUFFERED SOLUTION", "drug_information": { "unit": "1000.000000", "type": "UN" }, "code_information": [ { "code": "P8252000097", "type": "NDC" } ], "standard_charges": [ { "minimum": 13.12, "maximum": 1158.0, "gross_charge": 46.55, "discounted_cash": 25.6, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.0, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.42, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.41, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.55, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.34, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.88, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.84, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.96, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.12, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.57, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.91, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.4, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.65, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.45, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.42, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.01, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.91, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.96, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.0, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.42, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "FORMOTEROL FUMARATE 20 MCG/2ML IN NEBU", "drug_information": { "unit": "2.000000", "type": "UN" }, "code_information": [ { "code": "00093406130", "type": "NDC" } ], "standard_charges": [ { "minimum": 10.25, "maximum": 34.19, "gross_charge": 36.37, "discounted_cash": 20.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.09, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.86, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.1, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.81, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.58, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.46, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.79, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.75, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.19, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.25, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.91, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.28, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.81, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.73, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.19, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.48, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.86, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.91, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.28, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.09, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.86, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "FOSAPREPITANT DIMEGLUMINE 150 MG IV SOLR", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "71839010401", "type": "NDC" } ], "standard_charges": [ { "minimum": 14.04, "maximum": 46.84, "gross_charge": 49.83, "discounted_cash": 27.41, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.9, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.21, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.86, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.21, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.5, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.85, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.8, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.84, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.85, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.04, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.36, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.37, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.56, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.84, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.02, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.21, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.61, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.37, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.85, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.9, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.21, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "FOSCARNET 24 MG/ML IVPB (CENTRAL)", "drug_information": { "unit": "250.000000", "type": "UN" }, "code_information": [ { "code": "76310002425_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 27.47, "maximum": 1094.99, "gross_charge": 1164.88, "discounted_cash": 640.68, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 675.63, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.47, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 931.9, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 986.65, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 338.98, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 559.14, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 697.76, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 696.6, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1094.99, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1025.09, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 328.26, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 990.15, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 873.66, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 410.39, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 792.12, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1094.99, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 912.1, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.09, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 926.08, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 873.66, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1025.09, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 675.63, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.47, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "FOSCARNET INTRAVITREAL INJ (2400 MCG/0.1ML)", "drug_information": { "unit": "0.100000", "type": "UN" }, "code_information": [ { "code": "76310002425", "type": "NDC" } ], "standard_charges": [ { "minimum": 27.47, "maximum": 750.17, "gross_charge": 798.05, "discounted_cash": 438.93, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 462.87, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.47, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 638.44, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 675.95, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 232.23, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 383.06, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 478.03, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 477.23, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 750.17, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 702.28, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 224.89, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 678.34, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 598.54, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 281.15, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 542.67, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 750.17, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 624.87, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.09, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 634.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 598.54, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 702.28, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 462.87, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.47, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "FOSCARNET SODIUM 6000 MG/250ML IV SOLN", "drug_information": { "unit": "250.000000", "type": "UN" }, "code_information": [ { "code": "76310002425_3", "type": "NDC" } ], "standard_charges": [ { "minimum": 27.47, "maximum": 1094.99, "gross_charge": 1164.88, "discounted_cash": 640.68, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 675.63, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.47, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 931.9, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 986.65, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 338.98, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 559.14, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 697.76, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 696.6, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1094.99, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1025.09, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 328.26, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 990.15, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 873.66, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 410.39, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 792.12, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1094.99, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 912.1, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.09, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 926.08, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 873.66, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1025.09, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 675.63, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.47, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "FOSFOMYCIN TROMETHAMINE 3 G PO PACK", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "70700026894", "type": "NDC" } ], "standard_charges": [ { "minimum": 33.45, "maximum": 111.58, "gross_charge": 118.7, "discounted_cash": 65.29, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 68.85, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 64.81, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 94.96, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 100.54, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.54, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 56.98, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 71.1, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 70.98, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 111.58, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 104.46, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.45, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 100.9, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 89.03, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.82, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 80.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 111.58, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 92.94, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 64.81, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 94.37, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 89.03, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 104.46, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 68.85, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 64.81, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "FOSINOPRIL SODIUM 10 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "43547038609", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "FOSPHENYTOIN SODIUM 100 MG PE/2ML IJ SOLN", "drug_information": { "unit": "2.000000", "type": "UN" }, "code_information": [ { "code": "00069600125", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "FOSPHENYTOIN SODIUM 500 MG PE/10ML IJ SOLN", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "00641613710", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Fragmenting of kidney stone", "code_information": [ { "code": "50590", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2542.24, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1883.14, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 7881.43, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 14316.55, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2542.24, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 14316.55, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Free fascial flap microvasc", "code_information": [ { "code": "15758", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 9248.17, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 16780.97, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 16780.97, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Frenulotomy of penis", "code_information": [ { "code": "54164", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1509.96, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1118.49, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 5255.12, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 9546.51, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1509.96, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 9546.51, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Fth gr fr f/c/c/m/n/ax/g/h/f", "code_information": [ { "code": "15240", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1348.33, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 998.76, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 8302.65, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 15065.3, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1348.33, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 15065.3, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Fth grf fr n/e/e/l 20 sqcm/<", "code_information": [ { "code": "15260", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1348.33, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 998.76, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 9593.23, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 17758.06, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1348.33, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 17758.06, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Fth grf fr s/a/l 20 sq cm/<", "code_information": [ { "code": "15220", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1348.33, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 998.76, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 7690.41, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 13954.37, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1348.33, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 13954.37, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Fth grf fr trnk 20 sq cm/<", "code_information": [ { "code": "15200", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1348.33, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 998.76, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 11991.62, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 21758.99, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1348.33, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 21758.99, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "FULVESTRANT 250 MG/5ML IM SOSY", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "00143902202", "type": "NDC" } ], "standard_charges": [ { "minimum": 4.1, "maximum": 186.2, "gross_charge": 198.09, "discounted_cash": 108.95, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 114.89, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.1, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 158.47, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 167.78, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 57.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 95.08, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 118.66, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 118.46, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 186.2, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 174.32, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.82, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 168.38, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 148.57, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 69.79, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 134.7, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 186.2, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 155.1, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.54, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 157.48, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 148.57, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 174.32, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 114.89, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.1, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "FUROSEMIDE 1 MCG/ML SOLN FOR DESENSITIZATION", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "0054329446", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, 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"methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "FUROSEMIDE 1 MG/ML SOLN FOR DESENSITIZATION", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "0054329446_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, 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94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "FUROSEMIDE 10 MCG/ML SOLN FOR DESENSITIZATION", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "0054329446_3", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", 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"payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "FUROSEMIDE 10 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "0054429725", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "FUROSEMIDE 10 MG/ML IJ SOLN", "drug_information": { "unit": "2.000000", "type": "UN" }, "code_information": [ { "code": "71288020303", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 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"N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { 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"standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "FUROSEMIDE 10 MG/ML IJ SOLN (NICU)", "drug_information": { "unit": "2.000000", "type": "UN" }, "code_information": [ { "code": "36000028225_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", 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"percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "FUROSEMIDE 10 MG/ML IJ SOLN 10 ML VIAL (BULK CHARGE)", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "00409610210", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "FUROSEMIDE 10 MG/ML IJ SOLN 2 ML VIAL (BULK CHARGE)", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "36000028225_3", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "FUROSEMIDE 10 MG/ML IJ SOLN 4 ML VIAL (BULK CHARGE)", "drug_information": { "unit": "4.000000", "type": "UN" }, "code_information": [ { "code": "36000028325", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "FUROSEMIDE 10 MG/ML PO SOLN", "drug_information": { "unit": "4.000000", "type": "UN" }, "code_information": [ { "code": "68094075662", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "FUROSEMIDE 100 MCG/ML SOLN FOR DESENSITIZATION", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "0054329446_4", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "FUROSEMIDE 20 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00904717761", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "FUROSEMIDE 40 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00904717861", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "FUROSEMIDE 80 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "4229147001", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Fuse hand bones with graft", "code_information": [ { "code": "25825", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 5265.64, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3900.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 31804.36, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 57803.12, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5265.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 57803.12, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Fuse pancreas cyst and bowel", "code_information": [ { "code": "48520", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 11713.64, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 21254.6, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 21254.6, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Fusion of ankle joint open", "code_information": [ { "code": "27870", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 9484.13, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 7025.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 19609.58, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 35581.9, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 9484.13, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 35581.9, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Fusion of big toe joint", "code_information": [ { "code": "28750", "type": "HCPCS" }, { "code": "28755", "type": "HCPCS" }, { "code": "28760", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 5265.64, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3900.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 18003.47, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 32683.14, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5265.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 32683.14, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Fusion of facial/other nerve", "code_information": [ { "code": "64868", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 34495.13, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 62592.01, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 62592.01, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Fusion of finger joint", "code_information": [ { "code": "26860", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2391.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1771.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 11095.53, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 20133.01, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2391.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 20133.01, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Fusion of finger tendons", "code_information": [ { "code": "26471", "type": "HCPCS" }, { "code": "26474", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2391.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1771.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 873.82, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 9321.33, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 16913.7, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2391.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1179.66, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 16913.7, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Fusion of foot bones", "code_information": [ { "code": "28715", "type": "HCPCS" }, { "code": "28725", "type": "HCPCS" }, { "code": "28730", "type": "HCPCS" }, { "code": "28735", "type": "HCPCS" }, { "code": "28740", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 9484.13, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 7025.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3900.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 39398.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 71488.29, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 9484.13, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5265.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 71488.29, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Fusion of hand bones", "code_information": [ { "code": "25820", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 5265.64, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3900.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 20794.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 37731.04, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5265.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 37731.04, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Fusion of knuckle", "code_information": [ { "code": "26850", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 5265.64, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3900.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 14385.26, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 27157.98, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5265.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 27157.98, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Fusion of knuckle joint", "code_information": [ { "code": "26516", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2391.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1771.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 14385.26, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 27157.98, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2391.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 27157.98, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Fusion of spermatic ducts", "code_information": [ { "code": "54901", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2542.24, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1883.14, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 23441.42, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 42534.82, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2542.24, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 42534.82, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Fusion of tendons at wrist", "code_information": [ { "code": "25300", "type": "HCPCS" }, { "code": "25301", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2391.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1771.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 11109.86, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 20159.02, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2391.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 20159.02, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Fusion of thumb", "code_information": [ { "code": "26841", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 5265.64, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3900.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 22185.58, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 40256.09, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5265.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 40256.09, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Fusion of toes", "code_information": [ { "code": "28280", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2391.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1771.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 14125.24, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 25630.48, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2391.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 25630.48, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Fusion/graft of finger joint", "code_information": [ { "code": "26862", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2391.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1771.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 14886.92, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 27012.56, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2391.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 27012.56, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Fusion/graft of wrist joint", "code_information": [ { "code": "25810", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 9484.13, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 7025.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 18126.14, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 32890.22, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 9484.13, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 32890.22, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Fxjl abl lsr 1st 100 sq cm", "code_information": [ { "code": "0479T", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 451.2, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 334.22, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 2415.65, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 4383.25, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 451.2, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 4383.25, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "G-esoph reflx tst w/electrod", "code_information": [ { "code": "91035", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 391.11, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 289.71, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 3080.17, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 6147.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 391.11, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 6147.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "GABAPENTIN 100 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687058001", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "GABAPENTIN 250 MG/5ML PO SOLN", "drug_information": { "unit": "6.000000", "type": "UN" }, "code_information": [ { "code": "42192060840", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.05, "maximum": 6.85, "gross_charge": 7.29, "discounted_cash": 4.01, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.23, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.98, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.83, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.12, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.5, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.36, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.85, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.42, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.05, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.2, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.47, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.57, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.96, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.85, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.71, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.98, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.47, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.42, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.23, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.98, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "GABAPENTIN 300 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687059101", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "GABAPENTIN 400 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687060201", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "GALANTAMINE HYDROBROMIDE 4 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68084072921", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.84, "maximum": 6.14, "gross_charge": 6.53, "discounted_cash": 3.59, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.79, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.22, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.53, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.9, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.91, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.9, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.14, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.75, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.84, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.55, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.9, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.3, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.44, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.14, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.11, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.19, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.9, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.75, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.79, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "GALANTAMINE HYDROBROMIDE 8 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "65862045960", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "GALANTAMINE HYDROBROMIDE ER 24 MG PO CP24", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "47335083783", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.93, "maximum": 9.76, "gross_charge": 10.38, "discounted_cash": 5.71, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.02, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.67, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.3, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.79, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.02, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.98, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.22, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.21, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.13, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.93, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.82, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.79, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.66, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.06, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.67, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.25, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.79, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.13, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.02, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.67, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "GALLIUM CITRATE GA 67 2 MCI/ML IV SOLN", "drug_information": { "unit": "4.000000", "type": "UN" }, "code_information": [ { "code": "11994012106", "type": "NDC" } ], "standard_charges": [ { "minimum": 169.93, "maximum": 566.82, "gross_charge": 603.0, "discounted_cash": 331.65, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 349.74, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 329.24, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 482.4, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 510.74, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 175.47, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 289.44, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 361.2, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 360.59, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 566.82, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 530.64, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 169.93, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 512.55, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 452.25, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 212.44, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 410.04, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 566.82, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 472.15, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 329.24, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 479.39, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 452.25, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 530.64, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 349.74, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 329.24, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "GALLIUM GA 68 DOTATATE IV", "drug_information": { "unit": "0.930000", "type": "UN" }, "code_information": [ { "code": "69488000140", "type": "NDC" } ], "standard_charges": [ { "minimum": 27.9, "maximum": 9138.89, "gross_charge": 9722.22, "discounted_cash": 5347.22, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5638.89, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.9, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7777.78, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8234.72, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2829.17, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4666.67, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5823.61, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 5813.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9138.89, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8555.55, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2739.72, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8263.89, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7291.67, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3425.14, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6611.11, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 9138.89, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7612.5, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.66, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7729.16, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7291.67, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8555.55, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5638.89, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.9, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "GALLIUM GA 68 GOZETOTIDE 0.5-5 MCI/ML IV SOLN", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "76394264203", "type": "NDC" } ], "standard_charges": [ { "minimum": 203.2, "maximum": 11128.99, "gross_charge": 11839.35, "discounted_cash": 6511.64, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 6866.82, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 203.2, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9471.48, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10027.93, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3445.25, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5682.89, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7091.77, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 7079.93, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11128.99, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10418.63, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3336.33, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10063.45, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8879.51, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 4171.0, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 8050.76, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 11128.99, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 9270.21, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 274.33, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 9412.28, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8879.51, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10418.63, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6866.82, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 203.2, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "GALSULFASE 1 MG/ML IV SOLN", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "68135002001", "type": "NDC" } ], "standard_charges": [ { "minimum": 1983.31, "maximum": 6615.72, "gross_charge": 7038.0, "discounted_cash": 3870.9, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4082.04, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3842.75, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5630.4, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5961.19, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2048.06, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3378.24, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4215.76, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4208.72, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6615.72, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6193.44, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1983.31, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5982.3, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5278.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2479.49, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4785.84, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6615.72, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5510.75, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3842.75, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5595.21, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5278.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6193.44, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4082.04, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3842.75, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "GANCICLOVIR 0.15 % OP GEL", "drug_information": { "unit": "5.000000", "type": "GR" }, "code_information": [ { "code": "24208053535", "type": "NDC" } ], "standard_charges": [ { "minimum": 479.91, "maximum": 1600.82, "gross_charge": 1703.0, "discounted_cash": 936.65, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 987.74, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 929.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1362.4, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1442.44, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 495.57, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 817.44, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1020.1, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 1018.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1600.82, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1498.64, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 479.91, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1447.55, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1277.25, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 599.97, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.04, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1600.82, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1333.45, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 929.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1353.89, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1277.25, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1498.64, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 987.74, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 929.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "GANCICLOVIR INTRAVITREAL INJ (2 MG/0.05 ML)", "drug_information": { "unit": "0.050000", "type": "UN" }, "code_information": [ { "code": "08252000111", "type": "NDC" } ], "standard_charges": [ { "minimum": 45.08, "maximum": 150.36, "gross_charge": 159.96, "discounted_cash": 87.98, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 92.78, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.34, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 127.97, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 135.49, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.55, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 76.78, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 95.82, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 95.66, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 150.36, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 140.76, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.08, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 135.97, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 119.97, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 56.35, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 108.77, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 150.36, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 125.25, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.34, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 127.17, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 119.97, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 140.76, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 92.78, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.34, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "GANCICLOVIR INTRAVITREAL INJ (2 MG/0.1ML)", "drug_information": { "unit": "0.100000", "type": "UN" }, "code_information": [ { "code": "6332331510", "type": "NDC" } ], "standard_charges": [ { "minimum": 45.08, "maximum": 150.36, "gross_charge": 159.96, "discounted_cash": 87.98, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 92.78, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.34, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 127.97, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 135.49, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.55, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 76.78, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 95.82, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 95.66, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 150.36, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 140.76, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.08, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 135.97, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 119.97, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 56.35, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 108.77, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 150.36, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 125.25, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.34, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 127.17, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 119.97, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 140.76, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 92.78, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.34, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "GANCICLOVIR SODIUM 500 MG/10ML IV SOLN", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "25021018510", "type": "NDC" } ], "standard_charges": [ { "minimum": 22.92, "maximum": 76.45, "gross_charge": 81.33, "discounted_cash": 44.73, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.17, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 44.41, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.06, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 68.89, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.67, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.04, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 48.72, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 48.64, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 76.45, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 71.57, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.92, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 69.13, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.65, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.3, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 76.45, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.68, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 44.41, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 64.66, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 71.57, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.17, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 44.41, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "GARLIC 1000 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "74312012326", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "GARLIC 500 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "79854060025", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Gastric bypass incl small i", "code_information": [ { "code": "43847", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 3811.54, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 6916.14, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 6916.14, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Gastric motility studies", "code_information": [ { "code": "91020", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 391.11, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 289.71, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 5255.89, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 9536.9, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 391.11, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": 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88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 72.26, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 217.95, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 192.31, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 90.33, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All 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charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 192.31, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 225.64, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 148.72, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 140.0, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "GELATIN ABSORBABLE 100 CM EX MISC", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00009035301", "type": "NDC" } ], "standard_charges": [ { "minimum": 12.74, "maximum": 1158.0, "gross_charge": 45.21, "discounted_cash": 24.87, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.22, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.68, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.24, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.7, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.08, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.04, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.5, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.78, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.74, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.43, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.91, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.93, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.74, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.5, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.4, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.68, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.94, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.91, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.78, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.22, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.68, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "GELATIN ABSORBABLE 100 EX MISC", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "63713001974", "type": "NDC" } ], "standard_charges": [ { "minimum": 13.95, "maximum": 1158.0, "gross_charge": 49.5, "discounted_cash": 27.23, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.71, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.03, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.97, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.4, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.76, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.65, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.6, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.53, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.56, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.95, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.08, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.13, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.44, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.66, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.53, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.76, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.03, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.35, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.13, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.56, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.71, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.03, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "GELATIN ABSORBABLE 12-7 MM EX MISC", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "63713001972", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.86, "maximum": 1158.0, "gross_charge": 10.14, "discounted_cash": 5.58, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.88, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.54, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.8, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.95, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.87, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.07, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.06, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.53, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.92, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.86, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.62, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.61, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.57, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.9, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.53, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.94, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.54, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.06, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.61, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.92, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.88, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.54, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "GELATIN ABSORBABLE EX FILM", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00009028301", "type": "NDC" } ], "standard_charges": [ { "minimum": 1158.0, "maximum": 6567.29, "gross_charge": 6986.48, "discounted_cash": 3842.56, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4052.16, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3814.62, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6064.26, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2033.07, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3353.51, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4184.9, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4177.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6567.29, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6148.1, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1968.79, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5938.51, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5239.86, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2461.34, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4750.81, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6567.29, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5470.41, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3814.62, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5554.25, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5239.86, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6148.1, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4052.16, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3814.62, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "GELATIN ABSORBABLE MT POWD", "drug_information": { "unit": "1.000000", "type": "GR" }, "code_information": [ { "code": "00009043304", "type": "NDC" } ], "standard_charges": [ { "minimum": 43.69, "maximum": 145.73, "gross_charge": 155.03, "discounted_cash": 85.27, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 89.92, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 84.65, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 124.02, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 131.31, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.11, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.41, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 92.86, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 92.71, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 145.73, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 136.43, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.69, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 131.78, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 116.27, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.62, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 105.42, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 145.73, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 121.39, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 84.65, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 123.25, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 116.27, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 136.43, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 89.92, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 84.65, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "GELATIN ADSORBABLE OP FILM", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00009029703", "type": "NDC" } ], "standard_charges": [ { "minimum": 190.38, "maximum": 635.06, "gross_charge": 675.6, "discounted_cash": 371.58, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 391.85, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 368.88, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 540.48, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 572.23, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 196.6, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 324.29, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 404.68, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 404.01, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 635.06, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 594.53, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 190.38, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 574.26, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 506.7, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 238.01, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 459.41, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 635.06, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 528.99, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 368.88, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 537.1, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 506.7, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 594.53, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 391.85, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 368.88, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "GELATIN SPONGE ABSORBABLE", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "63713001978", "type": "NDC" } ], "standard_charges": [ { "minimum": 52.07, "maximum": 1158.0, "gross_charge": 184.77, "discounted_cash": 101.62, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 107.17, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 100.88, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 160.38, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 53.77, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.69, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 110.68, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 110.49, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 173.68, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 162.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.07, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 157.05, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 138.58, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 125.64, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 173.68, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 144.67, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 100.88, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 146.89, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 138.58, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 162.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 107.17, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 100.88, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "GEMCITABINE HCL 1 G IV SOLR", "drug_information": { "unit": "26.300000", "type": "UN" }, "code_information": [ { "code": "25021023550", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "GEMCITABINE HCL 2 G IV SOLR", "drug_information": { "unit": "53.000000", "type": "UN" }, "code_information": [ { "code": "00409018701", "type": "NDC" } ], "standard_charges": [ { "minimum": 202.66, "maximum": 676.03, "gross_charge": 719.18, "discounted_cash": 395.55, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 417.12, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 392.67, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 575.34, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 609.15, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 209.28, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 345.21, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 430.79, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 430.07, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 676.03, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 632.88, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 202.66, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 611.3, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 539.39, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 253.37, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 489.04, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 676.03, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 563.12, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 392.67, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 571.75, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 539.39, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 632.88, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 417.12, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 392.67, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "GEMCITABINE HCL 200 MG IV SOLR", "drug_information": { "unit": "5.300000", "type": "UN" }, "code_information": [ { "code": "00409018501", "type": "NDC" } ], "standard_charges": [ { "minimum": 13.7, "maximum": 45.68, "gross_charge": 48.6, "discounted_cash": 26.73, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.19, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.54, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.88, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.16, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.14, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.33, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.11, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.06, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.68, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.77, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.7, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.31, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.45, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.12, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.05, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.68, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.05, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.54, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.64, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.45, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.77, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.19, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.54, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "GEMFIBROZIL 600 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "50268035015", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "GEMTUZUMAB OZOGAMICIN 4.5 MG IV SOLR", "drug_information": { "unit": "4.500000", "type": "UN" }, "code_information": [ { "code": "00008451001", "type": "NDC" } ], "standard_charges": [ { "minimum": 8366.55, "maximum": 27908.3, "gross_charge": 29689.68, "discounted_cash": 16329.32, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 17220.01, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 16210.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23751.74, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 25147.16, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8639.7, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14251.05, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 17784.12, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 11394.0, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 27908.3, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 26126.92, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 8366.55, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 25236.23, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 22267.26, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 10459.67, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 20188.98, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27908.3, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23247.02, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 16210.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 15189.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 22267.26, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 26126.92, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 17220.01, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 16210.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "GENTAMICIN 10 MG/ML SYR <=30 MG (NICU)", "drug_information": { "unit": "2.000000", "type": "UN" }, "code_information": [ { "code": "63323017302", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "GENTAMICIN 10 MG/ML SYR <30 MG (ED PED SEPSIS)", "drug_information": { "unit": "2.000000", "type": "UN" }, "code_information": [ { "code": "63323017302_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "GENTAMICIN 10 MG/ML SYRINGE <= 30 MG (EXTENDED)", "drug_information": { "unit": "2.000000", "type": "UN" }, "code_information": [ { "code": "63323017302_4", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "GENTAMICIN 10 MG/ML SYRINGE <=30 MG (TRADITIONAL)", "drug_information": { "unit": "2.000000", "type": "UN" }, "code_information": [ { "code": "63323017302_5", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "GENTAMICIN 100 MG/50 ML RTU", "drug_information": { "unit": "50.000000", "type": "UN" }, "code_information": [ { "code": "00338051141", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "GENTAMICIN 120 MG/100 ML RTU", "drug_information": { "unit": "100.000000", "type": "UN" }, "code_information": [ { "code": "00338050748", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "GENTAMICIN 40 MG/ML SYRINGE (IM)", "drug_information": { "unit": "2.000000", "type": "UN" }, "code_information": [ { "code": "00409120703_4", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "GENTAMICIN 40 MG/ML SYRINGE (IM) (NICU)", "drug_information": { "unit": "2.000000", "type": "UN" }, "code_information": [ { "code": "00409120703_5", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "GENTAMICIN 5 MG/ML LOCK SYRINGE", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "08252000028", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "GENTAMICIN 80 MG/50 ML RTU", "drug_information": { "unit": "50.000000", "type": "UN" }, "code_information": [ { "code": "00338050941", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "GENTAMICIN 80 MG/50 ML RTU (EXTENDED)", "drug_information": { "unit": "50.000000", "type": "UN" }, "code_information": [ { "code": "00338050941_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "GENTAMICIN 80 MG/50 ML RTU (TRADITIONAL)", "drug_information": { "unit": "50.000000", "type": "UN" }, "code_information": [ { "code": "00338050941_3", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "GENTAMICIN OPHTHALMIC SOLN 15 MG/ML", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "08252004000", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "GENTAMICIN SUBCONJUNCTIVAL INJ (20 MG/0.5 ML)", "drug_information": { "unit": "0.500000", "type": "UN" }, "code_information": [ { "code": "08252001100", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "GENTAMICIN SULFATE 0.1 % EX CREA", "drug_information": { "unit": "15.000000", "type": "GR" }, "code_information": [ { "code": "00713068315", "type": "NDC" } ], "standard_charges": [ { "minimum": 4.24, "maximum": 14.13, "gross_charge": 15.03, "discounted_cash": 8.27, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.72, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.21, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.02, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.73, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.21, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.0, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.99, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.13, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.23, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.24, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.78, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.3, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.22, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.13, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.77, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.21, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.95, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.23, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.72, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.21, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "GENTAMICIN SULFATE 0.1 % EX OINT", "drug_information": { "unit": "15.000000", "type": "GR" }, "code_information": [ { "code": "45802004635", "type": "NDC" } ], "standard_charges": [ { "minimum": 21.02, "maximum": 70.11, "gross_charge": 74.58, "discounted_cash": 41.02, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.26, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.72, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.66, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.7, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 44.67, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 44.6, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 70.11, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.63, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.02, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.94, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.27, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.71, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 70.11, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 58.4, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.72, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.29, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.94, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.63, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.26, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.72, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "GENTAMICIN SULFATE 0.3 % OP SOLN", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "61314063305", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "GENTAMICIN SULFATE 10 MG/ML IJ SOLN", "drug_information": { "unit": "2.000000", "type": "UN" }, "code_information": [ { "code": "63323017302_3", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "GENTAMICIN SULFATE 40 MG/ML 2 ML VIAL (BULK CHARGE)", "drug_information": { "unit": "2.000000", "type": "UN" }, "code_information": [ { "code": "00409120703", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "GENTAMICIN SULFATE 40 MG/ML IJ SOLN", "drug_information": { "unit": "2.000000", "type": "UN" }, "code_information": [ { "code": "00409120703_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "GENTAMICIN SULFATE FOR INHALATION", "drug_information": { "unit": "2.000000", "type": "UN" }, "code_information": [ { "code": "00409120703_3", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "GLATIRAMER ACETATE 20 MG/ML SC SOSY", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00781323434", "type": "NDC" } ], "standard_charges": [ { "minimum": 27.2, "maximum": 127.43, "gross_charge": 96.53, "discounted_cash": 53.09, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.99, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 94.39, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 77.22, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 81.76, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.09, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.33, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 57.82, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 57.72, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 90.74, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 84.95, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.05, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 72.4, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.01, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.64, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 90.74, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.58, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 127.43, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 76.74, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 72.4, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 84.95, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.99, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 94.39, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "Glaucoma surgery", "code_information": [ { "code": "66160", "type": "HCPCS" }, { "code": "66170", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1681.13, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1245.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 17096.32, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 31021.57, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1681.13, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 31021.57, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "GLIMEPIRIDE 2 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68084032601", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "GLIPIZIDE 10 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "50268036215", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "GLIPIZIDE 5 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "50268036115", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "GLIPIZIDE ER 10 MG PO TB24", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "59651027001", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "GLIPIZIDE ER 2.5 MG PO TB24", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687076821", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "GLIPIZIDE ER 5 MG PO TB24", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68084011101", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "GLOFITAMAB-GXBM 10 MG/10ML IV SOLN", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "50242012701", "type": "NDC" } ], "standard_charges": [ { "minimum": 1474.77, "maximum": 29682.05, "gross_charge": 31576.65, "discounted_cash": 17367.16, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 18314.46, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1474.77, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 25261.32, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 26745.42, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9188.81, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15156.79, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 18914.41, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 11394.0, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 29682.05, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 27787.45, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 8898.3, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 26840.15, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23682.49, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11124.45, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 21472.12, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 29682.05, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24724.52, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1990.94, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 15189.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23682.49, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 27787.45, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 18314.46, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1474.77, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "GLOFITAMAB-GXBM 2.5 MG/2.5ML IV SOLN", "drug_information": { "unit": "2.500000", "type": "UN" }, "code_information": [ { "code": "50242012501", "type": "NDC" } ], "standard_charges": [ { "minimum": 1474.77, "maximum": 7420.49, "gross_charge": 7894.14, "discounted_cash": 4341.78, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4578.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1474.77, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6315.31, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6686.34, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2297.19, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3789.19, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4728.59, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4720.7, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7420.49, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6946.84, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2224.57, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6710.02, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5920.61, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2781.11, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5368.02, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7420.49, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6181.11, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1990.94, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6275.84, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5920.61, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6946.84, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4578.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1474.77, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "GLUCAGON (RDNA) 1 MG (MULTI-GPI)", "drug_information": { "unit": "0.500000", "type": "UN" }, "code_information": [ { "code": "00548585000", "type": "NDC" } ], "standard_charges": [ { "minimum": 105.0, "maximum": 953.54, "gross_charge": 1014.4, "discounted_cash": 557.92, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 588.35, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 105.0, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 811.52, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 859.2, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 295.19, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 486.91, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 607.63, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 606.61, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 953.54, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 892.67, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 285.86, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 862.24, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 760.8, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 357.37, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 689.79, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 953.54, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 794.28, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 141.74, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 806.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 760.8, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 892.67, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 588.35, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 105.0, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "GLUCAGON (RDNA) 1 MG IJ KIT", "drug_information": { "unit": "0.500000", "type": "ME" }, "code_information": [ { "code": "00548585000_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 105.0, "maximum": 953.54, "gross_charge": 1014.4, "discounted_cash": 557.92, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 588.35, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 105.0, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 811.52, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 859.2, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 295.19, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 486.91, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 607.63, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 606.61, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 953.54, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 892.67, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 285.86, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 862.24, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 760.8, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 357.37, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 689.79, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 953.54, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 794.28, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 141.74, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 806.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 760.8, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 892.67, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 588.35, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 105.0, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "GLUCARPIDASE 1000 UNITS IV SOLR", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "50633021011", "type": "NDC" } ], "standard_charges": [ { "minimum": 11394.0, "maximum": 93739.62, "gross_charge": 99723.0, "discounted_cash": 54847.65, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 57839.34, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 54448.76, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 79778.4, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 84465.38, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 29019.39, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 47867.04, "standard_charge_percentage": 48.0, "methodology": "percent of 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28101.94, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 84764.55, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 74792.25, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 35132.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 67811.64, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": 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"methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 87756.24, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 57839.34, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 54448.76, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "GLUCOSE 4 G PO CHEW", "drug_information": { "unit": "4.000000", "type": "UN" }, "code_information": [ { "code": "87701042599", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.7, "maximum": 5.69, "gross_charge": 6.05, "discounted_cash": 3.33, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.51, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.3, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.84, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.12, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", 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"additional_payer_notes": "N/A", "standard_charge_dollar": 5.32, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.7, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.14, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.54, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.13, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.11, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.69, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.74, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.3, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.81, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.54, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.32, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.51, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.3, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "GLUCOSE 40 % PO GEL", "drug_information": { "unit": "3.000000", "type": "UN" }, "code_information": [ { "code": "54758006289", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.62, "maximum": 5.41, "gross_charge": 5.76, "discounted_cash": 3.17, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.34, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.14, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.61, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.68, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.76, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.45, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.44, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.41, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.07, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.62, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.9, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.32, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.03, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.92, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.41, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.51, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.14, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.58, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.32, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.07, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.34, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.14, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "GLUCOSE TOLERANCE TEST 100 GM", "drug_information": { "unit": "300.000000", "type": "UN" }, "code_information": [ { "code": "04444000053", "type": "NDC" } ], "standard_charges": [ { "minimum": 3.02, "maximum": 1158.0, "gross_charge": 10.71, "discounted_cash": 5.89, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.21, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.85, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.3, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.12, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.14, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.42, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.07, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.42, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.02, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.1, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.03, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.77, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.28, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.07, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.39, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.85, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.51, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.03, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.42, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.21, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.85, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "GLUCOSE-VITAMIN C 4-6 GM-MG PO CHEW", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "38396050108", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "GLUTARALDEHYDE 0.625% EX SOLN", "drug_information": { "unit": "100.000000", "type": "UN" }, "code_information": [ { "code": "08252000107", "type": "NDC" } ], "standard_charges": [ { "minimum": 40.51, "maximum": 1158.0, "gross_charge": 143.75, "discounted_cash": 79.06, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 83.38, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 78.49, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 124.78, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.83, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 69.0, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.11, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 85.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 135.13, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 126.5, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.51, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 122.19, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 107.81, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.64, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 97.75, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 135.13, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 112.56, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 78.49, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 114.28, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 107.81, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 126.5, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 83.38, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 78.49, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "GLYBURIDE 2.5 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "72241003905", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "GLYBURIDE 5 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "2315505801", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "GLYCERIN (LAXATIVE) 1 G RE SUPP", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "58980040925", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "GLYCERIN (LAXATIVE) 1.2 G RE SUPP", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "46122022263", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 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"unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00132007924", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "GLYCERIN (LIQUID) 2.8 G RE SUPP", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00132019012", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "GLYCERIN 35 % MT LIQD", "drug_information": { "unit": "30.000000", "type": "UN" }, "code_information": [ { "code": "98669000201", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "GLYCERIN EX LIQD", "drug_information": { "unit": "177.000000", "type": "UN" }, "code_information": [ { "code": "37205001130", "type": "NDC" } ], "standard_charges": [ { "minimum": 3.86, "maximum": 12.86, "gross_charge": 13.68, "discounted_cash": 7.52, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.93, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.47, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.94, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.59, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.98, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.57, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.19, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.18, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.86, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.86, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.63, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.26, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.82, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.3, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.86, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.71, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.47, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.88, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.26, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.93, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.47, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "GLYCERIN LIQD", "drug_information": { "unit": "473.000000", "type": "UN" }, "code_information": [ { "code": "00395103116", "type": "NDC" } ], "standard_charges": [ { "minimum": 12.72, "maximum": 1158.0, "gross_charge": 45.13, "discounted_cash": 24.82, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.18, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.64, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.17, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.13, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.66, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.03, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.99, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.42, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.71, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.72, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.36, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.85, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.9, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.69, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.42, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.34, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.64, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.88, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.85, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.71, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.18, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.64, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "GLYCEROL PHENYLBUTYRATE 1.1 GM/ML PO LIQD", "drug_information": { "unit": "25.000000", "type": "UN" }, "code_information": [ { "code": "75987005006", "type": "NDC" } ], "standard_charges": [ { "minimum": 5614.02, "maximum": 18726.68, "gross_charge": 19922.0, "discounted_cash": 10957.1, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 11554.76, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 10877.41, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15937.6, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16873.93, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5797.3, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9562.56, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 11933.28, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 11394.0, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 18726.68, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17531.36, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 5614.02, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16933.7, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14941.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 7018.52, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 13546.96, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 18726.68, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 15598.93, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 10877.41, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 15189.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14941.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17531.36, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 11554.76, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 10877.41, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "GLYCINE DILUENT PH12 IV SOLN", "drug_information": { "unit": "50.000000", "type": "UN" }, "code_information": [ { "code": "00173085702", "type": "NDC" } ], "standard_charges": [ { "minimum": 12.4, "maximum": 1158.0, "gross_charge": 43.99, "discounted_cash": 24.19, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.51, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.02, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.18, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.8, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.12, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.35, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.31, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.35, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.71, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.4, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.99, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.5, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.91, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.35, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.44, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.02, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.97, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.99, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.71, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.51, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.02, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "GLYCINE POWD", "drug_information": { "unit": "100000.000000", "type": "ME" }, "code_information": [ { "code": "38779246505", "type": "NDC" } ], "standard_charges": [ { "minimum": 10.88, "maximum": 1158.0, "gross_charge": 38.6, "discounted_cash": 21.23, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.39, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.08, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.5, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.23, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.53, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.12, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.08, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.28, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.97, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.88, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.81, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.95, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.6, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.25, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.28, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.22, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.08, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.69, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.95, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.97, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.39, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.08, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "GLYCINE UROLOGIC 1.5 % IR SOLN", "drug_information": { "unit": "3000.000000", "type": "UN" }, "code_information": [ { "code": "00338028947", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 1158.0, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.72, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "GLYCOPYRROLATE 0.2 MG/ML IJ SOLN", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00143968225_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.28, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.38, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "GLYCOPYRROLATE 0.2 MG/ML IJ SOLN|DISCARDED DRUG NOT ADMINISTERED", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00143968225", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.28, "maximum": 1.36, "gross_charge": 1.45, "discounted_cash": 0.8, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.84, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.23, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.42, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.7, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.87, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.87, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.36, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.28, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.41, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.23, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.09, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.51, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.99, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.36, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.14, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.38, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.15, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.09, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.28, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.84, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "GLYCOPYRROLATE 1 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00904670961", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "GLYCOPYRROLATE 1 MG/5ML IJ SOLN", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "70860078105_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.28, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.38, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "GLYCOPYRROLATE 1 MG/5ML IJ SOLN|DISCARDED DRUG NOT ADMINISTERED", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "70860078105", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.28, "maximum": 5.83, "gross_charge": 6.2, "discounted_cash": 3.41, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.96, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.25, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.8, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.98, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.71, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.71, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.83, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.46, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.75, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.27, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.65, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.22, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.83, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.85, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.38, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.93, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.65, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.46, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "GLYCOPYRROLATE 1 MG/5ML PO SOLN", "drug_information": { "unit": "473.000000", "type": "UN" }, "code_information": [ { "code": "31722001647", "type": "NDC" } ], "standard_charges": [ { "minimum": 84.6, "maximum": 282.19, "gross_charge": 300.2, "discounted_cash": 165.11, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 174.12, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 163.91, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 240.16, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 254.27, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.36, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 144.1, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 179.82, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 179.52, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 282.19, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 264.18, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 84.6, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 255.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 225.15, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 105.76, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 204.14, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 282.19, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 235.06, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 163.91, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 238.66, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 225.15, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 264.18, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 174.12, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 163.91, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "GOLIMUMAB 100 MG/ML SC SOAJ", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "57894007102", "type": "NDC" } ], "standard_charges": [ { "minimum": 5754.6, "maximum": 19195.6, "gross_charge": 20420.85, "discounted_cash": 11231.47, "setting": "inpatient", 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], "additional_generic_notes": "" } ] }, { "description": "GOLIMUMAB 50 MG/0.5ML SC SOAJ", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "57894007002", "type": "NDC" } ], "standard_charges": [ { "minimum": 4102.91, "maximum": 13686.08, "gross_charge": 14559.66, "discounted_cash": 8007.81, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 8444.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 7949.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11647.73, "standard_charge_percentage": 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"percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4008.43, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5002.18, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4993.83, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7849.84, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7348.78, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2353.28, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7098.26, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6263.17, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2942.02, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { 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"percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6263.17, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7348.78, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4843.52, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 368.42, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "GOSERELIN ACETATE 3.6 MG SC IMPL", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "70720095036", "type": "NDC" } ], "standard_charges": [ { "minimum": 368.42, "maximum": 3733.0, "gross_charge": 3971.28, "discounted_cash": 2184.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2303.34, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 368.42, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3177.02, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", 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"additional_payer_notes": "N/A", "standard_charge_dollar": 3733.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3494.73, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1119.11, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3375.59, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2978.46, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1399.08, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2700.47, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3733.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3109.51, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 497.37, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3157.17, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2978.46, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3494.73, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2303.34, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 368.42, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "Graft repair of spine defect", "code_information": [ { "code": "63710", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 33869.24, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 61456.39, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 61456.39, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "GRANISETRON HCL 1 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "51991073520", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.41, "maximum": 4.71, "gross_charge": 5.01, "discounted_cash": 2.76, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.91, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.74, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { 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"percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.71, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.41, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.26, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.77, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.41, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.71, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", 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"payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.91, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.74, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "GRANISETRON HCL 1 MG/ML IV SOLN", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "67457086301", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of 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"standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 81559.51, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Grfg autol fat lipo 50 cc/<", "code_information": [ { "code": "15771", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2698.5, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1998.89, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 12646.85, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", 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1998.89, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 14171.23, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 25713.91, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2698.5, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 25713.91, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "GRISEOFULVIN MICROSIZE 500 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "23155086501", "type": "NDC" } ], "standard_charges": [ { "minimum": 3.9, "maximum": 13.0, "gross_charge": 13.83, "discounted_cash": 7.61, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.02, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.55, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.06, "standard_charge_percentage": 80.0, 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"standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.17, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.9, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.76, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.37, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.87, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.4, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.83, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.55, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.99, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.37, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.17, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.02, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.55, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "GUAIFENESIN 100 MG/5ML PO LIQD", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "00121148800", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "GUAIFENESIN 200 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00904515460", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "GUAIFENESIN ER 600 MG PO TB12", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68084057201", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "GUAIFENESIN-CODEINE 100-10 MG/5ML PO SOLN", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "00121177505", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.25, "maximum": 7.52, "gross_charge": 8.0, "discounted_cash": 4.4, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.4, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.78, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.33, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.84, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.79, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.25, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.8, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.82, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.44, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.26, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.36, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "GUAIFENESIN-DM 100-10 MG/5ML PO SYRP", "drug_information": { "unit": "237.000000", "type": "UN" }, "code_information": [ { "code": "58657050508", "type": "NDC" } ], "standard_charges": [ { "minimum": 3.83, "maximum": 12.77, "gross_charge": 13.58, "discounted_cash": 7.47, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.88, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.41, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.86, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.95, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.52, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.13, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.12, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.77, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.95, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.83, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.54, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.19, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.78, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.23, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.77, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.63, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.41, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.19, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.95, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.88, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.41, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "GUANFACINE HCL 1 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "R0591044401", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "GUANFACINE HCL 2 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "50268037415", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "GUANFACINE HCL ER 1 MG PO TB24", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00228285011", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "GUANFACINE HCL ER 2 MG PO TB24", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "70436004001", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "GUANFACINE HCL ER 3 MG PO TB24", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00228285311", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "HAEMOPHILUS B POLYSAC CONJ VAC 10 MCG IJ SOLR", "drug_information": { "unit": "0.500000", "type": "UN" }, "code_information": [ { "code": "58160072615", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "HAEMOPHILUS B POLYSAC CONJ VAC 7.5 MCG/0.5 ML IM SUSP", "drug_information": { "unit": "0.500000", "type": "UN" }, "code_information": [ { "code": "00006489700", "type": "NDC" } ], "standard_charges": [ { "minimum": 18.61, "maximum": 62.08, "gross_charge": 66.04, "discounted_cash": 36.32, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.3, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.83, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.94, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.22, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.7, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.56, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.49, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 62.08, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 58.12, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.61, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 56.13, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.53, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.27, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 44.91, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 62.08, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 51.71, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.5, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.53, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 58.12, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.3, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "HAEMOPHILUS B POLYSAC CONJ VAC IM SOLR", "drug_information": { "unit": "0.500000", "type": "UN" }, "code_information": [ { "code": "49281054503", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "HALOBETASOL PROPIONATE 0.05 % EX OINT", "drug_information": { "unit": "50.000000", "type": "GR" }, "code_information": [ { "code": "45802013132", "type": "NDC" } ], "standard_charges": [ { "minimum": 27.26, "maximum": 90.95, "gross_charge": 96.75, "discounted_cash": 53.21, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 56.12, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.83, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 77.4, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 81.95, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.15, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.44, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 57.95, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 57.86, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 90.95, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 85.14, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.26, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.24, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 72.56, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.79, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 90.95, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.76, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.83, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 76.92, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 72.56, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 85.14, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 56.12, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.83, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "HALOPERIDOL 0.5 MG PO TABS", "drug_information": { "unit": "2.000000", "type": "UN" }, "code_information": [ { "code": "R0378035101", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "HALOPERIDOL 1 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "51079073401", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "HALOPERIDOL 10 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68084024901", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "HALOPERIDOL 2 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "51079073520", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "HALOPERIDOL 5 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687016101", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "HALOPERIDOL DECANOATE 100 MG/ML IM SOLN", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "71288050302", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "HALOPERIDOL DECANOATE 50 MG/ML IM SOLN", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "10147092103", "type": "NDC" } ], "standard_charges": [ { "minimum": 16.52, "maximum": 55.11, "gross_charge": 58.63, "discounted_cash": 32.25, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.01, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.9, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.66, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.06, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.14, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.12, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.06, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.11, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 51.59, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.52, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.84, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.97, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.66, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.87, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.11, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.91, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.61, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.97, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 51.59, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.01, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "HALOPERIDOL LACTATE 2 MG/ML PO CONC", "drug_information": { "unit": "0.250000", "type": "UN" }, "code_information": [ { "code": "54838050140", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "HALOPERIDOL LACTATE 5 MG/ML IJ SOLN", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "67457042612", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Hand tendon reconstruction", "code_information": [ { "code": "26502", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2391.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1771.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 14493.26, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 26313.82, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2391.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 26313.82, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Harvest allogeneic stem cell", "code_information": [ { "code": "38205", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 9471.12, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 17189.1, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 17189.1, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Harvest auto stem cells", "code_information": [ { "code": "38206", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1208.31, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 8105.38, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 14707.35, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1208.31, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 14707.35, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Harvest eye tissue alograft", "code_information": [ { "code": "68371", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 8650.23, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 999999999.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "HB ECT-CONVULSIVE THERAPY", "code_information": [ { "code": "RRUCLARN-9019087000-1000-90870-0901-2540-Y", "type": "CDM" } ], "standard_charges": [ { "minimum": 289.71, "maximum": 2583.0, "gross_charge": 2540.0, "discounted_cash": 1397.0, "setting": "outpatient", "payers_information": [ { "payer_name": "OBH USBHPC", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1962.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1473.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 289.71, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1981.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1877.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 739.14, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1219.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1989.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 1518.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2305.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1736.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 715.77, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1800.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1905.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 894.84, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2583.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2033.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1988.82, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 391.11, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "HealthCare Partners HMO", "plan_name": "HMO-Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1100.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2019.3, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1905.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "OBH USBHPC", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2226.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1736.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1473.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 289.71, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "Per Unit" } ] }, { "description": "HB MULTIPLE FAMILY GROUP THERAPY", "code_information": [ { "code": "RRUCLARN-9169084900-1000-90849-0916-410-Y", "type": "CDM" } ], "standard_charges": [ { "minimum": 87.73, "maximum": 1805.0, "gross_charge": 410.0, "discounted_cash": 225.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 237.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.73, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 355.88, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 119.31, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 196.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 245.59, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 245.18, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 410.0, "standard_charge_percentage": 100.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 364.9, "standard_charge_percentage": 89.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 115.54, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 348.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 307.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO-Eating Disorder", "additional_payer_notes": "N/A", "standard_charge_dollar": 410.0, "standard_charge_percentage": 100.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 144.44, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 278.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 410.0, "standard_charge_percentage": 100.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO-Eating Disorder", "additional_payer_notes": "N/A", "standard_charge_dollar": 364.9, "standard_charge_percentage": 89.0, "methodology": "percent of total billed charges" }, { "payer_name": "OBH USBHPC", "plan_name": "All Products-Eating Disorder", "additional_payer_notes": "N/A", "standard_charge_dollar": 1591.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products-Eating Disorder", "additional_payer_notes": "N/A", "standard_charge_dollar": 410.0, "standard_charge_percentage": 100.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 321.03, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 118.43, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "OBH USBHPC", "plan_name": "All Products-Eating Disorder", "additional_payer_notes": "N/A", "standard_charge_dollar": 1805.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 325.95, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 307.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 364.9, "standard_charge_percentage": 89.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO-Eating Disorder", "additional_payer_notes": "N/A", "standard_charge_dollar": 364.9, "standard_charge_percentage": 89.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 237.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.73, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "HB OP PSYCHOTHERAPY 60MIN WITHOUT MED SERVICE", "code_information": [ { "code": "RRUCLARN-9149083701-1000-90837-0914-570-Y", "type": "CDM" } ], "standard_charges": [ { "minimum": 87.73, "maximum": 1805.0, "gross_charge": 570.0, "discounted_cash": 313.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 330.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.73, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1657.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 482.79, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 165.87, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 273.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 341.43, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 340.86, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 570.0, "standard_charge_percentage": 100.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 507.3, "standard_charge_percentage": 89.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 160.63, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 484.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 427.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO-Eating Disorder", "additional_payer_notes": "N/A", "standard_charge_dollar": 570.0, "standard_charge_percentage": 100.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 200.81, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 387.6, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 570.0, "standard_charge_percentage": 100.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO-Eating Disorder", "additional_payer_notes": "N/A", "standard_charge_dollar": 507.3, "standard_charge_percentage": 89.0, "methodology": "percent of total billed charges" }, { "payer_name": "OBH USBHPC", "plan_name": "All Products-Eating Disorder", "additional_payer_notes": "N/A", "standard_charge_dollar": 1591.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products-Eating Disorder", "additional_payer_notes": "N/A", "standard_charge_dollar": 570.0, "standard_charge_percentage": 100.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 446.31, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 118.43, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "OBH USBHPC", "plan_name": "All Products-Eating Disorder", "additional_payer_notes": "N/A", "standard_charge_dollar": 1805.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 453.15, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 427.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 507.3, "standard_charge_percentage": 89.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO-Eating Disorder", "additional_payer_notes": "N/A", "standard_charge_dollar": 507.3, "standard_charge_percentage": 89.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 330.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.73, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "HB PHP EARLY CHILDHOOD PER HOUR", "code_information": [ { "code": "RRUCLARN-9159085302-1000-90899-0915-250-Y", "type": "CDM" } ], "standard_charges": [ { "minimum": 16.27, "maximum": 1805.0, "gross_charge": 250.0, "discounted_cash": 137.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 145.0, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.27, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 217.0, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 72.75, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 120.0, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 149.75, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 149.5, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 250.0, "standard_charge_percentage": 100.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 222.5, "standard_charge_percentage": 89.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 70.45, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 212.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 187.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO-Eating Disorder", "additional_payer_notes": "N/A", "standard_charge_dollar": 250.0, "standard_charge_percentage": 100.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.08, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 170.0, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 250.0, "standard_charge_percentage": 100.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO-Eating Disorder", "additional_payer_notes": "N/A", "standard_charge_dollar": 222.5, "standard_charge_percentage": 89.0, "methodology": "percent of total billed charges" }, { "payer_name": "OBH USBHPC", "plan_name": "All Products-Eating Disorder", "additional_payer_notes": "N/A", "standard_charge_dollar": 1591.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products-Eating Disorder", "additional_payer_notes": "N/A", "standard_charge_dollar": 250.0, "standard_charge_percentage": 100.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 195.75, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.96, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "OBH USBHPC", "plan_name": "All Products-Eating Disorder", "additional_payer_notes": "N/A", "standard_charge_dollar": 1805.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 198.75, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 187.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 222.5, "standard_charge_percentage": 89.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO-Eating Disorder", "additional_payer_notes": "N/A", "standard_charge_dollar": 222.5, "standard_charge_percentage": 89.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 145.0, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.27, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "HB PHP PSYCHOTHERAPY 30MIN WITHOUT MED SERVICE", "code_information": [ { "code": "RRUCLARN-9149083200-1000-90832-0914-320-Y", "type": "CDM" } ], "standard_charges": [ { "minimum": 87.73, "maximum": 1657.0, "gross_charge": 320.0, "discounted_cash": 176.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 185.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.73, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1657.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 271.04, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.12, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 153.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 191.68, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 191.36, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 320.0, "standard_charge_percentage": 100.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 284.8, "standard_charge_percentage": 89.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 90.18, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 272.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 240.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO-Eating Disorder", "additional_payer_notes": "N/A", "standard_charge_dollar": 320.0, "standard_charge_percentage": 100.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 112.74, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 217.6, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 320.0, "standard_charge_percentage": 100.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO-Eating Disorder", "additional_payer_notes": "N/A", "standard_charge_dollar": 284.8, "standard_charge_percentage": 89.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products-Eating Disorder", "additional_payer_notes": "N/A", "standard_charge_dollar": 320.0, "standard_charge_percentage": 100.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 250.56, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 118.43, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 254.4, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 240.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 284.8, "standard_charge_percentage": 89.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO-Eating Disorder", "additional_payer_notes": "N/A", "standard_charge_dollar": 284.8, "standard_charge_percentage": 89.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 185.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.73, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "HB PHP PSYCHOTHERAPY 45MIN WITHOUT MED SERVICE", "code_information": [ { "code": "RRUCLARN-9149083400-1000-90834-0914-450-Y", "type": "CDM" } ], "standard_charges": [ { "minimum": 87.73, "maximum": 1657.0, "gross_charge": 450.0, "discounted_cash": 247.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 261.0, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.73, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1657.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 381.15, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 130.95, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 216.0, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 269.55, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 269.1, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 450.0, "standard_charge_percentage": 100.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 400.5, "standard_charge_percentage": 89.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 126.81, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 382.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 337.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO-Eating Disorder", "additional_payer_notes": "N/A", "standard_charge_dollar": 450.0, "standard_charge_percentage": 100.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 158.54, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 306.0, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 450.0, "standard_charge_percentage": 100.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO-Eating Disorder", "additional_payer_notes": "N/A", "standard_charge_dollar": 400.5, "standard_charge_percentage": 89.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products-Eating Disorder", "additional_payer_notes": "N/A", "standard_charge_dollar": 450.0, "standard_charge_percentage": 100.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 352.35, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 118.43, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 357.75, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 337.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 400.5, "standard_charge_percentage": 89.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO-Eating Disorder", "additional_payer_notes": "N/A", "standard_charge_dollar": 400.5, "standard_charge_percentage": 89.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 261.0, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.73, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "HB PSYCH DIAGNOSTIC INTERVIEW EXAM", "code_information": [ { "code": "RRUCLARN-9009079100-1000-90791-0900-550-Y", "type": "CDM" } ], "standard_charges": [ { "minimum": 87.73, "maximum": 1805.0, "gross_charge": 550.0, "discounted_cash": 302.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 319.0, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.73, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1657.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 465.85, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 160.05, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 264.0, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 329.45, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 328.9, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 550.0, "standard_charge_percentage": 100.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 489.5, "standard_charge_percentage": 89.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 154.99, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 467.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 412.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO-Eating Disorder", "additional_payer_notes": "N/A", "standard_charge_dollar": 550.0, "standard_charge_percentage": 100.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 193.77, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 374.0, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 550.0, "standard_charge_percentage": 100.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO-Eating Disorder", "additional_payer_notes": "N/A", "standard_charge_dollar": 489.5, "standard_charge_percentage": 89.0, "methodology": "percent of total billed charges" }, { "payer_name": "OBH USBHPC", "plan_name": "All Products-Eating Disorder", "additional_payer_notes": "N/A", "standard_charge_dollar": 1591.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products-Eating Disorder", "additional_payer_notes": "N/A", "standard_charge_dollar": 550.0, "standard_charge_percentage": 100.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 430.65, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 118.43, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "OBH USBHPC", "plan_name": "All Products-Eating Disorder", "additional_payer_notes": "N/A", "standard_charge_dollar": 1805.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 437.25, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 412.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 489.5, "standard_charge_percentage": 89.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO-Eating Disorder", "additional_payer_notes": "N/A", "standard_charge_dollar": 489.5, "standard_charge_percentage": 89.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 319.0, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.73, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "HB VENIPUNCTURE BLOOD DRAW", "code_information": [ { "code": "RRUCLARN-3003641500-48-36415-0300-30-Y", "type": "CDM" }, { "code": "RRUCLARN-3003641500MCAL-48-99000-0300-30-Y", "type": "CDM" } ], "standard_charges": [ { "minimum": 4.96, "maximum": 1158.0, "gross_charge": 30.0, "discounted_cash": 16.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.4, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.96, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.38, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.04, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.73, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.4, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.97, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.94, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.2, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.4, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.45, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.57, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.4, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.2, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.49, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.7, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.38, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.85, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.4, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.4, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.96, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.38, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "HB FAMILY THER 50MIN W OUT PATIENT IOP", "code_information": [ { "code": "RRUCLARN-9169084601-1000-90846-0916-580-Y", "type": "CDM" } ], "standard_charges": [ { "minimum": 87.73, "maximum": 1805.0, "gross_charge": 580.0, "discounted_cash": 319.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 336.4, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.73, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 503.44, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 168.78, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC 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charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 163.44, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 493.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 435.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO-Eating Disorder", "additional_payer_notes": "N/A", "standard_charge_dollar": 580.0, "standard_charge_percentage": 100.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 204.33, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 394.4, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 580.0, "standard_charge_percentage": 100.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO-Eating Disorder", "additional_payer_notes": "N/A", "standard_charge_dollar": 516.2, "standard_charge_percentage": 89.0, "methodology": "percent of total billed charges" }, { "payer_name": "OBH USBHPC", "plan_name": "All Products-Eating Disorder", "additional_payer_notes": "N/A", "standard_charge_dollar": 1591.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products-Eating Disorder", "additional_payer_notes": "N/A", "standard_charge_dollar": 580.0, "standard_charge_percentage": 100.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 454.14, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 118.43, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "OBH USBHPC", "plan_name": "All Products-Eating Disorder", "additional_payer_notes": "N/A", "standard_charge_dollar": 1805.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 461.1, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 435.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 516.2, "standard_charge_percentage": 89.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO-Eating Disorder", "additional_payer_notes": "N/A", "standard_charge_dollar": 516.2, "standard_charge_percentage": 89.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 336.4, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.73, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "HB FAMILY THER 50MIN W OUT PATIENT PHP", "code_information": [ { "code": "RRUCLARN-9169084600-1000-90846-0916-580-Y", "type": "CDM" } ], "standard_charges": [ { "minimum": 87.73, "maximum": 1805.0, "gross_charge": 580.0, "discounted_cash": 319.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 336.4, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.73, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 503.44, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 168.78, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 278.4, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 347.42, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 346.84, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 580.0, "standard_charge_percentage": 100.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 516.2, "standard_charge_percentage": 89.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 163.44, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 493.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 435.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO-Eating Disorder", "additional_payer_notes": "N/A", "standard_charge_dollar": 580.0, "standard_charge_percentage": 100.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 204.33, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 394.4, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 580.0, "standard_charge_percentage": 100.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO-Eating Disorder", "additional_payer_notes": "N/A", "standard_charge_dollar": 516.2, "standard_charge_percentage": 89.0, "methodology": "percent of total billed charges" }, { "payer_name": "OBH USBHPC", "plan_name": "All Products-Eating Disorder", "additional_payer_notes": "N/A", "standard_charge_dollar": 1591.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products-Eating Disorder", "additional_payer_notes": "N/A", "standard_charge_dollar": 580.0, "standard_charge_percentage": 100.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 454.14, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 118.43, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "OBH USBHPC", "plan_name": "All Products-Eating Disorder", "additional_payer_notes": "N/A", "standard_charge_dollar": 1805.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 461.1, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 435.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 516.2, "standard_charge_percentage": 89.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO-Eating Disorder", "additional_payer_notes": "N/A", "standard_charge_dollar": 516.2, "standard_charge_percentage": 89.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 336.4, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.73, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "HB FAMILY THER 50MIN WITH PATIENT IOP", "code_information": [ { "code": "RRUCLARN-9169084701-1000-90847-0916-580-Y", "type": "CDM" } ], "standard_charges": [ { "minimum": 87.73, "maximum": 1805.0, "gross_charge": 580.0, "discounted_cash": 319.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 336.4, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.73, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 503.44, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 168.78, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 278.4, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 347.42, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 346.84, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 580.0, "standard_charge_percentage": 100.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 516.2, "standard_charge_percentage": 89.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 163.44, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 493.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 435.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO-Eating Disorder", "additional_payer_notes": "N/A", "standard_charge_dollar": 580.0, "standard_charge_percentage": 100.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 204.33, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 394.4, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 580.0, "standard_charge_percentage": 100.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO-Eating Disorder", "additional_payer_notes": "N/A", "standard_charge_dollar": 516.2, "standard_charge_percentage": 89.0, "methodology": "percent of total billed charges" }, { "payer_name": "OBH USBHPC", "plan_name": "All Products-Eating Disorder", "additional_payer_notes": "N/A", "standard_charge_dollar": 1591.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products-Eating Disorder", "additional_payer_notes": "N/A", "standard_charge_dollar": 580.0, "standard_charge_percentage": 100.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 454.14, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 118.43, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "OBH USBHPC", "plan_name": "All Products-Eating Disorder", "additional_payer_notes": "N/A", "standard_charge_dollar": 1805.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 461.1, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 435.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 516.2, "standard_charge_percentage": 89.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO-Eating Disorder", "additional_payer_notes": "N/A", "standard_charge_dollar": 516.2, "standard_charge_percentage": 89.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 336.4, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.73, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "HB FAMILY THER 50MIN WITH PATIENT PHP", "code_information": [ { "code": "RRUCLARN-9169084700-1000-90847-0916-580-Y", "type": "CDM" } ], "standard_charges": [ { "minimum": 87.73, "maximum": 1805.0, "gross_charge": 580.0, "discounted_cash": 319.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 336.4, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.73, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 503.44, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 168.78, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 278.4, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 347.42, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 346.84, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 580.0, "standard_charge_percentage": 100.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 516.2, "standard_charge_percentage": 89.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 163.44, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 493.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 435.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO-Eating Disorder", "additional_payer_notes": "N/A", "standard_charge_dollar": 580.0, "standard_charge_percentage": 100.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 204.33, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 394.4, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 580.0, "standard_charge_percentage": 100.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO-Eating Disorder", "additional_payer_notes": "N/A", "standard_charge_dollar": 516.2, "standard_charge_percentage": 89.0, "methodology": "percent of total billed charges" }, { "payer_name": "OBH USBHPC", "plan_name": "All Products-Eating Disorder", "additional_payer_notes": "N/A", "standard_charge_dollar": 1591.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products-Eating Disorder", "additional_payer_notes": "N/A", "standard_charge_dollar": 580.0, "standard_charge_percentage": 100.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 454.14, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 118.43, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "OBH USBHPC", "plan_name": "All Products-Eating Disorder", "additional_payer_notes": "N/A", "standard_charge_dollar": 1805.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 461.1, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 435.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 516.2, "standard_charge_percentage": 89.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO-Eating Disorder", "additional_payer_notes": "N/A", "standard_charge_dollar": 516.2, "standard_charge_percentage": 89.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 336.4, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.73, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "HB GROUP PSYCHOTHERAPY IOP", "code_information": [ { "code": "RRUCLARN-9159085301-1000-90853-0915-280-Y", "type": "CDM" } ], "standard_charges": [ { "minimum": 50.51, "maximum": 1805.0, "gross_charge": 280.0, "discounted_cash": 154.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 162.4, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.51, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 243.04, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 81.48, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 134.4, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 167.72, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 167.44, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 280.0, "standard_charge_percentage": 100.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 249.2, "standard_charge_percentage": 89.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 78.9, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 238.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 210.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO-Eating Disorder", "additional_payer_notes": "N/A", "standard_charge_dollar": 280.0, "standard_charge_percentage": 100.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 98.64, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 190.4, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 280.0, "standard_charge_percentage": 100.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO-Eating Disorder", "additional_payer_notes": "N/A", "standard_charge_dollar": 249.2, "standard_charge_percentage": 89.0, "methodology": "percent of total billed charges" }, { "payer_name": "OBH USBHPC", "plan_name": "All Products-Eating Disorder", "additional_payer_notes": "N/A", "standard_charge_dollar": 1591.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products-Eating Disorder", "additional_payer_notes": "N/A", "standard_charge_dollar": 280.0, "standard_charge_percentage": 100.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 219.24, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 68.18, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "OBH USBHPC", "plan_name": "All Products-Eating Disorder", "additional_payer_notes": "N/A", "standard_charge_dollar": 1805.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 222.6, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 210.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 249.2, "standard_charge_percentage": 89.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO-Eating Disorder", "additional_payer_notes": "N/A", "standard_charge_dollar": 249.2, "standard_charge_percentage": 89.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 162.4, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.51, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "HB GROUP PSYCHOTHERAPY PHP/IOP 45-50 MINS", "code_information": [ { "code": "RRUCLARN-9157041000-1000-G0410-0915-250-Y", "type": "CDM" } ], "standard_charges": [ { "minimum": 70.45, "maximum": 1805.0, "gross_charge": 250.0, "discounted_cash": 137.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 145.0, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 136.5, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1657.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 211.75, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 72.75, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 120.0, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 149.75, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 149.5, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 250.0, "standard_charge_percentage": 100.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 222.5, "standard_charge_percentage": 89.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 70.45, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 212.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 187.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO-Eating Disorder", "additional_payer_notes": "N/A", "standard_charge_dollar": 250.0, "standard_charge_percentage": 100.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.08, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 170.0, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 250.0, "standard_charge_percentage": 100.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO-Eating Disorder", "additional_payer_notes": "N/A", "standard_charge_dollar": 222.5, "standard_charge_percentage": 89.0, "methodology": "percent of total billed charges" }, { "payer_name": "OBH USBHPC", "plan_name": "All Products-Eating Disorder", "additional_payer_notes": "N/A", "standard_charge_dollar": 1591.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products-Eating Disorder", "additional_payer_notes": "N/A", "standard_charge_dollar": 250.0, "standard_charge_percentage": 100.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 195.75, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 136.5, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "OBH USBHPC", "plan_name": "All Products-Eating Disorder", "additional_payer_notes": "N/A", "standard_charge_dollar": 1805.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 198.75, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 187.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 222.5, "standard_charge_percentage": 89.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO-Eating Disorder", "additional_payer_notes": "N/A", "standard_charge_dollar": 222.5, "standard_charge_percentage": 89.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 145.0, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 136.5, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "HB ICU PSYCH", "code_information": [ { "code": "RRUCLARN-2000020400-1000--0204-7710-Y", "type": "CDM" } ], "standard_charges": [ { "minimum": 0.01, "maximum": 6833.0, "gross_charge": 7710.0, "discounted_cash": 4240.5, "setting": "inpatient", "payers_information": [ { "payer_name": "OBH USBHPC", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3059.0, "standard_charge_percentage": 100.0, "methodology": "per diem" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4471.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4281.0, "standard_charge_percentage": 100.0, "methodology": "per diem" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.01, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2243.61, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5966.0, "standard_charge_percentage": 100.0, "methodology": "per diem" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2627.0, "standard_charge_percentage": 100.0, "methodology": "per diem" }, { "payer_name": "Department of Mental Health (DMH)", "plan_name": "Medicaid", "additional_payer_notes": "N/A", "standard_charge_dollar": 1110.0, "standard_charge_percentage": 100.0, "methodology": "per diem" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3724.0, "standard_charge_percentage": 100.0, "methodology": "per diem" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3858.0, "standard_charge_percentage": 100.0, "methodology": "per diem" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1474.0, "standard_charge_percentage": 100.0, "methodology": "per diem" }, { "payer_name": "Kaiser", "plan_name": "All Products-Eating Disorder", "additional_payer_notes": "N/A", "standard_charge_dollar": 4773.0, "standard_charge_percentage": 100.0, "methodology": "per diem" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3530.0, "standard_charge_percentage": 100.0, "methodology": "per diem" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5782.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1659.0, "standard_charge_percentage": 100.0, "methodology": "per diem" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6833.0, "standard_charge_percentage": 100.0, "methodology": "per diem" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3724.0, "standard_charge_percentage": 100.0, "methodology": "per diem" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6036.93, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "HealthCare Partners HMO", "plan_name": "HMO-Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3100.0, "standard_charge_percentage": 100.0, "methodology": "per diem" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3504.0, "standard_charge_percentage": 100.0, "methodology": "per diem" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5782.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "OBH USBHPC", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3470.0, "standard_charge_percentage": 100.0, "methodology": "per diem" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3858.0, "standard_charge_percentage": 100.0, "methodology": "per diem" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4471.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "HB NONCHEMO IV INFUSION 1ST HOUR", "code_information": [ { "code": "RRUCLARN-2609636500-1000-96365-0260-940-Y", "type": "CDM" } ], "standard_charges": [ { "minimum": 115.04, "maximum": 883.6, "gross_charge": 940.0, "discounted_cash": 517.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 545.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 115.04, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 752.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 796.18, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 273.54, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 451.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 563.06, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 562.12, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 883.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 827.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 264.89, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 799.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 705.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 331.16, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 639.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 883.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 736.02, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 155.3, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 747.3, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 705.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 827.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 545.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 115.04, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "HB NONCHEMO IV PUSH EACH ADDL SEQUENTIAL", "code_information": [ { "code": "RRUCLARN-9409637500-1000-96375-0940-420-Y", "type": "CDM" } ], "standard_charges": [ { "minimum": 25.19, "maximum": 394.8, "gross_charge": 420.0, "discounted_cash": 231.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 243.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.19, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 336.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 355.74, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 122.22, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 201.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 251.58, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 251.16, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 394.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 369.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 118.36, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 357.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 315.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 147.97, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 285.6, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 394.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 328.86, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.01, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 333.9, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 315.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 369.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 243.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.19, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "HB NONCHEMO IV PUSH SINGLE INITIAL", "code_information": [ { "code": "RRUCLARN-9409637400-1000-96374-0940-800-Y", "type": "CDM" } ], "standard_charges": [ { "minimum": 115.04, "maximum": 752.0, "gross_charge": 800.0, "discounted_cash": 440.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 464.0, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 115.04, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 640.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 677.6, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 232.8, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 384.0, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 479.2, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 478.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 752.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 704.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 225.44, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 680.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 600.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 281.84, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 544.0, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 752.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 626.4, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 155.3, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 636.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 600.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 704.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 464.0, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 115.04, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "HB OP PSYCHOTHERAPY 30MIN WITHOUT MED SERVICE", "code_information": [ { "code": "RRUCLARN-9149083201-1000-90832-0914-320-Y", "type": "CDM" } ], "standard_charges": [ { "minimum": 87.73, "maximum": 1657.0, "gross_charge": 320.0, "discounted_cash": 176.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 185.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.73, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1657.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 271.04, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.12, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 153.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 191.68, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 191.36, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 320.0, "standard_charge_percentage": 100.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 284.8, "standard_charge_percentage": 89.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 90.18, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 272.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 240.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO-Eating Disorder", "additional_payer_notes": "N/A", "standard_charge_dollar": 320.0, "standard_charge_percentage": 100.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 112.74, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 217.6, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 320.0, "standard_charge_percentage": 100.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO-Eating Disorder", "additional_payer_notes": "N/A", "standard_charge_dollar": 284.8, "standard_charge_percentage": 89.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products-Eating Disorder", "additional_payer_notes": "N/A", "standard_charge_dollar": 320.0, "standard_charge_percentage": 100.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 250.56, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 118.43, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 254.4, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 240.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 284.8, "standard_charge_percentage": 89.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO-Eating Disorder", "additional_payer_notes": "N/A", "standard_charge_dollar": 284.8, "standard_charge_percentage": 89.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 185.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.73, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "HB OP PSYCHOTHERAPY 45MIN WITHOUT MED SERVICE", "code_information": [ { "code": "RRUCLARN-9149083401-1000-90834-0914-450-Y", "type": "CDM" } ], "standard_charges": [ { "minimum": 87.73, "maximum": 1657.0, "gross_charge": 450.0, "discounted_cash": 247.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 261.0, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.73, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1657.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 381.15, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 130.95, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 216.0, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 269.55, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 269.1, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 450.0, "standard_charge_percentage": 100.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 400.5, "standard_charge_percentage": 89.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 126.81, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 382.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 337.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO-Eating Disorder", "additional_payer_notes": "N/A", "standard_charge_dollar": 450.0, "standard_charge_percentage": 100.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 158.54, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 306.0, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 450.0, "standard_charge_percentage": 100.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO-Eating Disorder", "additional_payer_notes": "N/A", "standard_charge_dollar": 400.5, "standard_charge_percentage": 89.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products-Eating Disorder", "additional_payer_notes": "N/A", "standard_charge_dollar": 450.0, "standard_charge_percentage": 100.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 352.35, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 118.43, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 357.75, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 337.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 400.5, "standard_charge_percentage": 89.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO-Eating Disorder", "additional_payer_notes": "N/A", "standard_charge_dollar": 400.5, "standard_charge_percentage": 89.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 261.0, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.73, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "HB OT THERAPY SVC PHP/IOP PER SESSION >45MINS", "code_information": [ { "code": "RRUCLARN-4307012901-1000-G0129-0430-350-Y", "type": "CDM" } ], "standard_charges": [ { "minimum": 98.63, "maximum": 1805.0, "gross_charge": 350.0, "discounted_cash": 192.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 203.0, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 191.1, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 303.8, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 101.85, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 168.0, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 209.65, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 209.3, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 350.0, "standard_charge_percentage": 100.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 311.5, "standard_charge_percentage": 89.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 98.63, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 297.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 262.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO-Eating Disorder", "additional_payer_notes": "N/A", "standard_charge_dollar": 350.0, "standard_charge_percentage": 100.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 123.31, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 238.0, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 350.0, "standard_charge_percentage": 100.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO-Eating Disorder", "additional_payer_notes": "N/A", "standard_charge_dollar": 311.5, "standard_charge_percentage": 89.0, "methodology": "percent of total billed charges" }, { "payer_name": "OBH USBHPC", "plan_name": "All Products-Eating Disorder", "additional_payer_notes": "N/A", "standard_charge_dollar": 1591.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products-Eating Disorder", "additional_payer_notes": "N/A", "standard_charge_dollar": 350.0, "standard_charge_percentage": 100.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 274.05, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 191.1, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "OBH USBHPC", "plan_name": "All Products-Eating Disorder", "additional_payer_notes": "N/A", "standard_charge_dollar": 1805.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 278.25, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 262.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 311.5, "standard_charge_percentage": 89.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO-Eating Disorder", "additional_payer_notes": "N/A", "standard_charge_dollar": 311.5, "standard_charge_percentage": 89.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 203.0, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 191.1, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "HB PHP ACTIVITY THERAPY PER SESSION", "code_information": [ { "code": "RRUCLARN-9047017600-1000-G0176-0904-390-Y", "type": "CDM" } ], "standard_charges": [ { "minimum": 109.9, "maximum": 1805.0, "gross_charge": 390.0, "discounted_cash": 214.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 226.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 212.94, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1657.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 330.33, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 113.49, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 187.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 233.61, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 233.22, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 390.0, "standard_charge_percentage": 100.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 347.1, "standard_charge_percentage": 89.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 109.9, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 331.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 292.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO-Eating Disorder", "additional_payer_notes": "N/A", "standard_charge_dollar": 390.0, "standard_charge_percentage": 100.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 137.4, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 265.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 390.0, "standard_charge_percentage": 100.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO-Eating Disorder", "additional_payer_notes": "N/A", "standard_charge_dollar": 347.1, "standard_charge_percentage": 89.0, "methodology": "percent of total billed charges" }, { "payer_name": "OBH USBHPC", "plan_name": "All Products-Eating Disorder", "additional_payer_notes": "N/A", "standard_charge_dollar": 1591.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products-Eating Disorder", "additional_payer_notes": "N/A", "standard_charge_dollar": 390.0, "standard_charge_percentage": 100.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 305.37, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 212.94, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "OBH USBHPC", "plan_name": "All Products-Eating Disorder", "additional_payer_notes": "N/A", "standard_charge_dollar": 1805.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 310.05, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 292.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 347.1, "standard_charge_percentage": 89.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO-Eating Disorder", "additional_payer_notes": "N/A", "standard_charge_dollar": 347.1, "standard_charge_percentage": 89.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 226.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 212.94, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "HB PSYCHOTHERAPY INTERACTIVE GROUP PHP/IOP 45-50 MINS", "code_information": [ { "code": "RRUCLARN-9157041100-1000-G0411-0915-190-Y", "type": "CDM" } ], "standard_charges": [ { "minimum": 53.54, "maximum": 1805.0, "gross_charge": 190.0, "discounted_cash": 104.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 110.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.74, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1657.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 160.93, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.29, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 91.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 113.81, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 113.62, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 190.0, "standard_charge_percentage": 100.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 169.1, "standard_charge_percentage": 89.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 53.54, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 161.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 142.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO-Eating Disorder", "additional_payer_notes": "N/A", "standard_charge_dollar": 190.0, "standard_charge_percentage": 100.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 66.94, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 129.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 190.0, "standard_charge_percentage": 100.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO-Eating Disorder", "additional_payer_notes": "N/A", "standard_charge_dollar": 169.1, "standard_charge_percentage": 89.0, "methodology": "percent of total billed charges" }, { "payer_name": "OBH USBHPC", "plan_name": "All Products-Eating Disorder", "additional_payer_notes": "N/A", "standard_charge_dollar": 1591.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products-Eating Disorder", "additional_payer_notes": "N/A", "standard_charge_dollar": 190.0, "standard_charge_percentage": 100.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 148.77, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.74, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "OBH USBHPC", "plan_name": "All Products-Eating Disorder", "additional_payer_notes": "N/A", "standard_charge_dollar": 1805.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 151.05, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 142.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 169.1, "standard_charge_percentage": 89.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO-Eating Disorder", "additional_payer_notes": "N/A", "standard_charge_dollar": 169.1, "standard_charge_percentage": 89.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 110.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.74, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "HB REMOTE MNTL HLTH SUBS DISORDER INIT 15-29 MINS", "code_information": [ { "code": "RRUCLARN-7803790000-1000-C7900-0780-120-Y", "type": "CDM" } ], "standard_charges": [ { "minimum": 16.27, "maximum": 112.8, "gross_charge": 120.0, "discounted_cash": 66.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 69.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.27, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 101.64, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.92, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 57.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 71.88, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 71.76, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 112.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 105.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.82, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 102.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 90.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.28, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 81.6, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 112.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.96, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.96, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 95.4, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 90.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 105.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 69.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.27, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "HB REMOTE MNTL HLTH SUBS DISORDER INIT 30-60 MINS  ", "code_information": [ { "code": "RRUCLARN-7803790100-1000-C7901-0780-320-Y", "type": "CDM" } ], "standard_charges": [ { "minimum": 50.51, "maximum": 300.8, "gross_charge": 320.0, "discounted_cash": 176.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 185.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.51, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 256.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 271.04, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.12, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 153.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 191.68, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 191.36, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 300.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 281.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 90.18, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 272.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 240.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 112.74, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 217.6, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 300.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 250.56, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 68.18, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 254.4, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 240.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 281.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 185.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.51, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "HB SEMIPRIVATE PSYCH", "code_information": [ { "code": "RRUCLARN-1200012400-1000--0124-6230-Y", "type": "CDM" } ], "standard_charges": [ { "minimum": 1110.0, "maximum": 5020.0, "gross_charge": 6230.0, "discounted_cash": 3426.5, "setting": "inpatient", "payers_information": [ { "payer_name": "OBH USBHPC", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2677.0, "standard_charge_percentage": 100.0, "methodology": "per diem" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3613.4, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3677.0, "standard_charge_percentage": 100.0, "methodology": "per diem" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3472.0, "standard_charge_percentage": 100.0, "methodology": "per diem" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1812.93, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3979.0, "standard_charge_percentage": 100.0, "methodology": "per diem" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2627.0, "standard_charge_percentage": 100.0, "methodology": "per diem" }, { "payer_name": "Department of Mental Health (DMH)", "plan_name": "Medicaid", "additional_payer_notes": "N/A", "standard_charge_dollar": 1110.0, "standard_charge_percentage": 100.0, "methodology": "per diem" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2931.0, "standard_charge_percentage": 100.0, "methodology": "per diem" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3858.0, "standard_charge_percentage": 100.0, "methodology": "per diem" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1474.0, "standard_charge_percentage": 100.0, "methodology": "per diem" }, { "payer_name": "Kaiser", "plan_name": "All Products-Eating Disorder", "additional_payer_notes": "N/A", "standard_charge_dollar": 4773.0, "standard_charge_percentage": 100.0, "methodology": "per diem" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3040.0, "standard_charge_percentage": 100.0, "methodology": "per diem" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4672.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO-Eating Disorder", "additional_payer_notes": "N/A", "standard_charge_dollar": 3594.0, "standard_charge_percentage": 100.0, "methodology": "per diem" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1659.0, "standard_charge_percentage": 100.0, "methodology": "per diem" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5020.0, "standard_charge_percentage": 100.0, "methodology": "per diem" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2931.0, "standard_charge_percentage": 100.0, "methodology": "per diem" }, { "payer_name": "Evernorth", "plan_name": "PPO-Eating Disorder", "additional_payer_notes": "N/A", "standard_charge_dollar": 3718.0, "standard_charge_percentage": 100.0, "methodology": "per diem" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products-Eating Disorder", "additional_payer_notes": "N/A", "standard_charge_dollar": 3594.0, "standard_charge_percentage": 100.0, "methodology": "per diem" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4878.09, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "OBH USBHPC", "plan_name": "All Products-Eating Disorder", "additional_payer_notes": "N/A", "standard_charge_dollar": 3440.0, "standard_charge_percentage": 100.0, "methodology": "per diem" }, { "payer_name": "HealthCare Partners HMO", "plan_name": "HMO-Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2100.0, "standard_charge_percentage": 100.0, "methodology": "per diem" }, { "payer_name": "Health Net", "plan_name": "HMO-Eating Disorder", "additional_payer_notes": "N/A", "standard_charge_dollar": 4653.0, "standard_charge_percentage": 100.0, "methodology": "per diem" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3504.0, "standard_charge_percentage": 100.0, "methodology": "per diem" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4672.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "OBH USBHPC", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3036.0, "standard_charge_percentage": 100.0, "methodology": "per diem" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3858.0, "standard_charge_percentage": 100.0, "methodology": "per diem" }, { "payer_name": "Evernorth", "plan_name": "HMO-Eating Disorder", "additional_payer_notes": "N/A", "standard_charge_dollar": 3718.0, "standard_charge_percentage": 100.0, "methodology": "per diem" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3613.4, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "HB SINGLE PSYCH", "code_information": [ { "code": "RRUCLARN-1100011400-1000--0114-6230-Y", "type": "CDM" } ], "standard_charges": [ { "minimum": 1110.0, "maximum": 5020.0, "gross_charge": 6230.0, "discounted_cash": 3426.5, "setting": "inpatient", "payers_information": [ { "payer_name": "OBH USBHPC", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2677.0, "standard_charge_percentage": 100.0, "methodology": "per diem" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3613.4, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3677.0, "standard_charge_percentage": 100.0, "methodology": "per diem" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3472.0, "standard_charge_percentage": 100.0, "methodology": "per diem" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1812.93, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3979.0, "standard_charge_percentage": 100.0, "methodology": "per diem" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2627.0, "standard_charge_percentage": 100.0, "methodology": "per diem" }, { "payer_name": "Department of Mental Health (DMH)", "plan_name": "Medicaid", "additional_payer_notes": "N/A", "standard_charge_dollar": 1110.0, "standard_charge_percentage": 100.0, "methodology": "per diem" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2931.0, "standard_charge_percentage": 100.0, "methodology": "per diem" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3858.0, "standard_charge_percentage": 100.0, "methodology": "per diem" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1474.0, "standard_charge_percentage": 100.0, "methodology": "per diem" }, { "payer_name": "Kaiser", "plan_name": "All Products-Eating Disorder", "additional_payer_notes": "N/A", "standard_charge_dollar": 4773.0, "standard_charge_percentage": 100.0, "methodology": "per diem" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3040.0, "standard_charge_percentage": 100.0, "methodology": "per diem" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4672.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO-Eating Disorder", "additional_payer_notes": "N/A", "standard_charge_dollar": 3594.0, "standard_charge_percentage": 100.0, "methodology": "per diem" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1659.0, "standard_charge_percentage": 100.0, "methodology": "per diem" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5020.0, "standard_charge_percentage": 100.0, "methodology": "per diem" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2931.0, "standard_charge_percentage": 100.0, "methodology": "per diem" }, { "payer_name": "Evernorth", "plan_name": "PPO-Eating Disorder", "additional_payer_notes": "N/A", "standard_charge_dollar": 3718.0, "standard_charge_percentage": 100.0, "methodology": "per diem" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products-Eating Disorder", "additional_payer_notes": "N/A", "standard_charge_dollar": 3594.0, "standard_charge_percentage": 100.0, "methodology": "per diem" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4878.09, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "OBH USBHPC", "plan_name": "All Products-Eating Disorder", "additional_payer_notes": "N/A", "standard_charge_dollar": 3440.0, "standard_charge_percentage": 100.0, "methodology": "per diem" }, { "payer_name": "HealthCare Partners HMO", "plan_name": "HMO-Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2100.0, "standard_charge_percentage": 100.0, "methodology": "per diem" }, { "payer_name": "Health Net", "plan_name": "HMO-Eating Disorder", "additional_payer_notes": "N/A", "standard_charge_dollar": 4653.0, "standard_charge_percentage": 100.0, "methodology": "per diem" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3504.0, "standard_charge_percentage": 100.0, "methodology": "per diem" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4672.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "OBH USBHPC", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3036.0, "standard_charge_percentage": 100.0, "methodology": "per diem" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3858.0, "standard_charge_percentage": 100.0, "methodology": "per diem" }, { "payer_name": "Evernorth", "plan_name": "HMO-Eating Disorder", "additional_payer_notes": "N/A", "standard_charge_dollar": 3718.0, "standard_charge_percentage": 100.0, "methodology": "per diem" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3613.4, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "HB TRAINING & EDUCATION SCHOOL PER SESSION", "code_information": [ { "code": "RRUCLARN-9427017700-1000-G0177-0942-240-Y", "type": "CDM" } ], "standard_charges": [ { "minimum": 67.63, "maximum": 1805.0, "gross_charge": 240.0, "discounted_cash": 132.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 139.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 131.04, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1657.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 203.28, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 69.84, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 115.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 143.76, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 143.52, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 240.0, "standard_charge_percentage": 100.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 213.6, "standard_charge_percentage": 89.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 67.63, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 204.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 180.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO-Eating Disorder", "additional_payer_notes": "N/A", "standard_charge_dollar": 240.0, "standard_charge_percentage": 100.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 84.55, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 163.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 240.0, "standard_charge_percentage": 100.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO-Eating Disorder", "additional_payer_notes": "N/A", "standard_charge_dollar": 213.6, "standard_charge_percentage": 89.0, "methodology": "percent of total billed charges" }, { "payer_name": "OBH USBHPC", "plan_name": "All Products-Eating Disorder", "additional_payer_notes": "N/A", "standard_charge_dollar": 1591.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products-Eating Disorder", "additional_payer_notes": "N/A", "standard_charge_dollar": 240.0, "standard_charge_percentage": 100.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 187.92, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 131.04, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "OBH USBHPC", "plan_name": "All Products-Eating Disorder", "additional_payer_notes": "N/A", "standard_charge_dollar": 1805.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 190.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 180.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 213.6, "standard_charge_percentage": 89.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO-Eating Disorder", "additional_payer_notes": "N/A", "standard_charge_dollar": 213.6, "standard_charge_percentage": 89.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 139.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 131.04, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "HB TRANSFUSION BLOOD/BLOOD COMPONENTS", "code_information": [ { "code": "RRUCLARN-3913643000-1000-36430-0391-1960-Y", "type": "CDM" } ], "standard_charges": [ { "minimum": 238.7, "maximum": 1842.4, "gross_charge": 1960.0, "discounted_cash": 1078.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1136.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 238.7, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1568.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1660.12, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 570.36, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 940.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1174.04, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 1172.08, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1842.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1724.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 552.33, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1666.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1470.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 690.51, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1332.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1842.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1534.68, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 322.25, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1558.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1470.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1724.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1136.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 238.7, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "HEMIN 350 MG IV SOLR", "drug_information": { "unit": "50.000000", "type": "UN" }, "code_information": [ { "code": "55292070255", "type": "NDC" } ], "standard_charges": [ { "minimum": 17.58, "maximum": 26475.6, "gross_charge": 28165.53, "discounted_cash": 15491.04, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 16336.01, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.58, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 22532.42, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23856.2, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8196.17, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13519.45, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 16871.15, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 11394.0, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 26475.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 24785.67, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 7937.05, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23940.7, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21124.15, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 9922.72, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 19152.56, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 26475.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { 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"methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 492.4, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 324.54, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 305.51, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "HEPARIN (PORCINE) IN NACL 1000-0.9 UT/500ML-% IV SOLN", "drug_information": { "unit": "500.000000", "type": "UN" }, "code_information": [ { "code": "00264987210", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 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"additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "HEPARIN (PORCINE) IN NACL 2000-0.9 UNIT/L-% IV SOLN", "drug_information": { "unit": "1000.000000", "type": "UN" }, "code_information": [ { "code": "00409222212", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", 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"payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": 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"payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", 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"additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, 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"description": "HEPARIN (PORCINE) IN NACL 25000-0.45 UT/250ML-% IV SOLN (PEDS)", "drug_information": { "unit": "250.000000", "type": "UN" }, "code_information": [ { "code": "00409765062", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": 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60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": 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"payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "HEPARIN (PORCINE) IN NACL 5000-0.9 UNIT/L-% IV SOLN", "drug_information": { "unit": "1000.000000", "type": "UN" }, "code_information": [ { "code": "08252000120", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "HEPARIN (PORCINE) IN NACL 5000-0.9 UT/500ML-% IV SOLN", "drug_information": { "unit": "500.000000", "type": "UN" }, "code_information": [ { "code": "08252000322", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "HEPARIN 100 UNITS/ML (CAPS)", "drug_information": { "unit": "250.000000", "type": "UN" }, "code_information": [ { "code": "00264958720", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "HEPARIN 20000 UNITS/20 ML SYRINGE (STRAIGHT DRUG)", "drug_information": { "unit": "30.000000", "type": "UN" }, "code_information": [ { "code": "00409272003", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "HEPARIN 25000 UNITS/250 ML 0.45 NACL RTU - ACS PROTOCOL", "drug_information": { "unit": "250.000000", "type": "UN" }, "code_information": [ { "code": "63323051774_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "HEPARIN 25000 UNITS/250 ML 0.45 NACL RTU - ANTI-XA LOW", "drug_information": { "unit": "250.000000", "type": "UN" }, "code_information": [ { "code": "63323051774_3", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { 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"methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", 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billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "HEPARIN 25000 UNITS/250 ML 0.45 NACL RTU - ANTI-XA VERY LOW", "drug_information": { "unit": "250.000000", "type": "UN" }, "code_information": [ { "code": "63323051774_5", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "HEPARIN 25000 UNITS/250 ML 0.45 NACL RTU - DIALYSIS ONLY", "drug_information": { "unit": "250.000000", "type": "UN" }, "code_information": [ { "code": "63323051774_6", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "HEPARIN 25000 UNITS/250 ML 0.45 NACL RTU - MCS/CT-ICU - ANTI-XA", "drug_information": { "unit": "250.000000", "type": "UN" }, "code_information": [ { "code": "63323051774_7", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, 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"additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "HEPARIN 25000 UNITS/250 ML 0.45 NACL RTU - MCS/CT-ICU - APTT", "drug_information": { "unit": "250.000000", "type": "UN" }, "code_information": [ { "code": "63323051774_8", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { 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31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { 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"additional_generic_notes": "" } ] }, { "description": "HEPARIN 25000 UNITS/250 ML 0.45 NACL RTU FOR STROKE ORDER SETS", "drug_information": { "unit": "250.000000", "type": "UN" }, "code_information": [ { "code": "63323051774_11", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, 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63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "HEPARIN 25000 UNITS/250 ML D5W RTU", "drug_information": { "unit": "250.000000", "type": "UN" }, "code_information": [ { "code": "63323052374", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "HEPARIN 25000 UNITS/250 ML D5W RTU (PEDS)", "drug_information": { "unit": "250.000000", "type": "UN" }, "code_information": [ { "code": "63323052374_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "HEPARIN 25000 UNITS/250 ML D5W RTU - ACS PROTOCOL", "drug_information": { "unit": "250.000000", "type": "UN" }, "code_information": [ { "code": "63323052374_3", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "HEPARIN 25000 UNITS/250 ML D5W RTU - ANTI-XA LOW", "drug_information": { "unit": "250.000000", "type": "UN" }, "code_information": [ { "code": "63323052374_4", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "HEPARIN 25000 UNITS/250 ML D5W RTU - ANTI-XA REGULAR", "drug_information": { "unit": "250.000000", "type": "UN" }, "code_information": [ { "code": "63323052374_5", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "HEPARIN 25000 UNITS/250 ML D5W RTU - ANTI-XA VERY LOW", "drug_information": { "unit": "250.000000", "type": "UN" }, "code_information": [ { "code": "63323052374_6", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "HEPARIN 25000 UNITS/250 ML D5W RTU - DIALYSIS ONLY", "drug_information": { "unit": "250.000000", "type": "UN" }, "code_information": [ { "code": "63323052374_7", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "HEPARIN 25000 UNITS/250 ML D5W RTU - MCS/CT-ICU - ANTI-XA", "drug_information": { "unit": "250.000000", "type": "UN" }, "code_information": [ { "code": "63323052374_8", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "HEPARIN 25000 UNITS/250 ML D5W RTU - MCS/CT-ICU - APTT", "drug_information": { "unit": "250.000000", "type": "UN" }, "code_information": [ { "code": "63323052374_9", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "HEPARIN 25000 UNITS/250 ML D5W RTU - NON-ACS PROTOCOL", "drug_information": { "unit": "250.000000", "type": "UN" }, "code_information": [ { "code": "63323052374_10", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "HEPARIN NA (PORK) LOCK FLSH PF 1 UNIT/ML IV SOLN", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "64253044425", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "HEPARIN SOD (PORK) LOCK FLUSH 10 UNIT/ML IV SOLN (MULTI-GPI)", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "08290306414", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "HEPARIN SOD (PORK) LOCK FLUSH 100 UNIT/ML IV SOLN (MULTI-GPI)", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "64253033335", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, 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"additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "00409272002", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": 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"payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN (APHERESIS)", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "00409272002_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, 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30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN - PER PROTOCOL", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "00409272002_3", "type": "NDC" } ], "standard_charges": [ { 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}, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "HEPARIN SODIUM (PORCINE) 5000 UNIT/ML IJ SOLN", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00409272301", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "HEPARIN SODIUM (PORCINE) PF 1000 UNIT/ML IJ SOLN", "drug_information": { "unit": "2.000000", "type": "UN" }, "code_information": [ { "code": "71288040003", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "HEPARIN SODIUM 1000 UNIT/ML SOLN 10 ML VIAL (BULK CHARGE)", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "00409272002_4", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "HEPATITIS A VACCINE 1440 EL U/ML IM SUSP", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "58160082652", "type": "NDC" } ], "standard_charges": [ { "minimum": 53.18, "maximum": 177.39, "gross_charge": 188.71, "discounted_cash": 103.79, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 109.45, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.04, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 150.97, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 159.84, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.91, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 90.58, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 113.04, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 112.85, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 177.39, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 166.06, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 53.18, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 160.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 141.53, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 66.48, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 128.32, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 177.39, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 147.76, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.04, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 150.02, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 141.53, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 166.06, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 109.45, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.04, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "HEPATITIS A VACCINE 25 UNIT/0.5ML IM SUSP", "drug_information": { "unit": "0.500000", "type": "UN" }, "code_information": [ { "code": "00006483141", "type": "NDC" } ], "standard_charges": [ { "minimum": 20.42, "maximum": 68.11, "gross_charge": 72.46, "discounted_cash": 39.85, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.03, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.56, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 57.97, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.37, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.09, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.78, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.33, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 68.11, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.76, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.42, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.59, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.35, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.53, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.27, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 68.11, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 56.74, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.56, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 57.61, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.35, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.76, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.03, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.56, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "HEPATITIS A VACCINE 720 EL U/0.5ML IM SUSP", "drug_information": { "unit": "0.500000", "type": "UN" }, "code_information": [ { "code": "58160082552", "type": "NDC" } ], "standard_charges": [ { "minimum": 18.89, "maximum": 63.02, "gross_charge": 67.04, "discounted_cash": 36.87, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.88, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.6, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 53.63, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 56.78, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.51, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.18, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.16, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.09, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.02, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.89, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 56.98, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.28, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.62, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.59, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.02, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.49, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.6, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 53.3, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.28, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.88, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.6, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "HEPATITIS A-HEP B RECOMB VAC 720-20 ELU-MCG/ML IM SUSY", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "58160081552", "type": "NDC" } ], "standard_charges": [ { "minimum": 77.27, "maximum": 257.74, "gross_charge": 274.19, "discounted_cash": 150.8, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 159.03, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 149.71, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 219.35, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 232.24, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 79.79, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 131.61, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 164.24, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 163.97, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 257.74, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 241.29, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 77.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 233.06, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 205.64, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.6, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 186.45, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 257.74, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 214.69, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 149.71, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 217.98, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 205.64, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 241.29, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 159.03, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 149.71, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "HEPATITIS B IMMUNE GLOBULIN 312 UNIT/ML IJ SOLN", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "70257005151", "type": "NDC" } ], "standard_charges": [ { "minimum": 37.49, "maximum": 1964.52, "gross_charge": 2089.92, "discounted_cash": 1149.46, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1212.15, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.49, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1671.94, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1770.16, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 608.17, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1003.16, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1251.86, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 1249.77, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1964.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1839.13, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 588.94, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1776.43, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1567.44, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 736.28, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1421.15, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1964.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1636.41, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.61, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1661.49, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1567.44, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1839.13, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1212.15, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.49, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "HEPATITIS B IMMUNE GLOBULIN IM", "drug_information": { "unit": "0.500000", "type": "UN" }, "code_information": [ { "code": "70257005151_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 37.49, "maximum": 1964.52, "gross_charge": 2089.92, "discounted_cash": 1149.46, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1212.15, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.49, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1671.94, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1770.16, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 608.17, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1003.16, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1251.86, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 1249.77, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1964.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1839.13, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 588.94, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1776.43, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1567.44, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 736.28, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1421.15, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1964.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1636.41, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.61, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1661.49, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1567.44, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1839.13, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1212.15, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.49, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "HEPATITIS B IMMUNE GLOBULIN IM SOLN (NICU)", "drug_information": { "unit": "0.500000", "type": "UN" }, "code_information": [ { "code": "70257005151_3", "type": "NDC" } ], "standard_charges": [ { "minimum": 37.49, "maximum": 1964.52, "gross_charge": 2089.92, "discounted_cash": 1149.46, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1212.15, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.49, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1671.94, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1770.16, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 608.17, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1003.16, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1251.86, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 1249.77, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1964.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1839.13, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 588.94, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1776.43, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1567.44, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 736.28, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1421.15, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1964.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1636.41, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.61, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1661.49, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1567.44, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1839.13, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1212.15, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.49, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "HEPATITIS B VAC RECOMB ADJ 20 MCG/0.5ML IM SOLN", "drug_information": { "unit": "0.500000", "type": "UN" }, "code_information": [ { "code": "43528000205", "type": "NDC" } ], "standard_charges": [ { "minimum": 77.99, "maximum": 260.14, "gross_charge": 276.74, "discounted_cash": 152.21, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 160.51, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 151.1, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 221.39, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 234.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 80.53, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 132.84, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 165.77, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 165.49, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 260.14, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 243.53, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 77.99, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 235.23, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 207.56, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 97.5, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 188.18, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 260.14, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 216.69, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 151.1, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 220.01, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 207.56, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 243.53, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 160.51, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 151.1, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "HEPATITIS B VAC RECOMB ADJ 20 MCG/0.5ML IM SOSY", "drug_information": { "unit": "0.500000", "type": "UN" }, "code_information": [ { "code": "43528000305", "type": "NDC" } ], "standard_charges": [ { "minimum": 116.79, "maximum": 389.58, "gross_charge": 414.45, "discounted_cash": 227.95, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 240.38, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 226.29, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 331.56, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 351.04, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 120.6, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 198.94, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 248.26, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 247.84, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 389.58, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 364.72, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 116.79, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 352.28, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 310.84, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 146.01, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 281.83, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 389.58, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 324.51, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 226.29, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 329.49, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 310.84, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 364.72, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 240.38, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 226.29, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "HEPATITIS B VAC RECOMBINANT 10 MCG/0.5ML IJ SUSY", "drug_information": { "unit": "0.500000", "type": "UN" }, "code_information": [ { "code": "58160082052", "type": "NDC" } ], "standard_charges": [ { "minimum": 12.85, "maximum": 42.86, "gross_charge": 45.6, "discounted_cash": 25.08, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.45, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.9, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.48, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.62, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.27, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.89, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.31, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.27, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.86, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.13, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.85, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.76, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.2, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.06, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.01, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.86, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.7, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.9, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.25, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.2, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.13, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.45, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.9, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "HEPATITIS B VAC RECOMBINANT 20 MCG/ML IJ SUSP", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "58160082111", "type": "NDC" } ], "standard_charges": [ { "minimum": 29.59, "maximum": 98.72, "gross_charge": 105.02, "discounted_cash": 57.76, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.91, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 57.34, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 84.02, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.95, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.56, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.41, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 62.91, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 62.8, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 98.72, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 92.42, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.59, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 89.27, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 78.77, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.0, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 71.41, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 98.72, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.23, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 57.34, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 83.49, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 78.77, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 92.42, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.91, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 57.34, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "HEPATITIS B VAC RECOMBINANT 20 MCG/ML IJ SUSP (4-DOSE)", "drug_information": { "unit": "2.000000", "type": "UN" }, "code_information": [ { "code": "58160082111_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 71.03, "maximum": 236.93, "gross_charge": 252.05, "discounted_cash": 138.63, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 146.19, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 137.62, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 201.64, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 213.49, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 73.35, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 120.98, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 150.98, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 150.73, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 236.93, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 221.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 71.03, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 214.24, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 189.04, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.8, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 171.39, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 236.93, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 197.36, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 137.62, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 200.38, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 189.04, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 221.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 146.19, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 137.62, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "HEPATITIS B VAC RECOMBINANT 20 MCG/ML IJ SUSY", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "58160082152", "type": "NDC" } ], "standard_charges": [ { "minimum": 29.59, "maximum": 98.72, "gross_charge": 105.02, "discounted_cash": 57.76, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.91, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 57.34, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 84.02, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.95, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.56, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.41, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 62.91, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 62.8, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 98.72, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 92.42, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.59, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 89.27, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 78.77, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.0, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 71.41, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 98.72, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.23, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 57.34, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 83.49, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 78.77, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 92.42, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.91, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 57.34, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "HEPATITIS B VAC RECOMBINANT 40 MCG/ML IJ SUSP", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00006499200", "type": "NDC" } ], "standard_charges": [ { "minimum": 101.28, "maximum": 337.85, "gross_charge": 359.42, "discounted_cash": 197.68, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 208.46, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 196.24, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 287.54, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 304.43, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 104.59, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 172.52, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 215.29, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 214.93, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 337.85, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 316.29, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 101.28, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 305.51, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 269.57, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 126.62, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 244.41, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 337.85, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 281.43, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 196.24, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 285.74, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 269.57, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 316.29, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 208.46, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 196.24, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "HETASTARCH-NACL 6-0.9 % IV SOLN", "drug_information": { "unit": "500.000000", "type": "UN" }, "code_information": [ { "code": "00409724803", "type": "NDC" } ], "standard_charges": [ { "minimum": 19.73, "maximum": 1158.0, "gross_charge": 70.0, "discounted_cash": 38.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.76, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.37, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.93, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.86, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.73, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.66, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.6, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.81, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.65, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "HETASTARCH-NACL 6-0.9 % IV SOLN (GI USE ONLY)", "drug_information": { "unit": "500.000000", "type": "UN" }, "code_information": [ { "code": "00409724803_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 19.73, "maximum": 1158.0, "gross_charge": 70.0, "discounted_cash": 38.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.76, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.37, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.93, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.86, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.73, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.66, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.6, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.81, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.65, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "HETASTARCH-NACL 6-0.9 % IV SOLN (GI USE ONLY) IVAS", "drug_information": { "unit": "500.000000", "type": "UN" }, "code_information": [ { "code": "00409724803_3", "type": "NDC" } ], "standard_charges": [ { "minimum": 19.73, "maximum": 1158.0, "gross_charge": 70.0, "discounted_cash": 38.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.76, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.37, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.93, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.86, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.73, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.66, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.6, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.81, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.65, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "HEXAMINOLEVULINATE HCL 100 MG IS SOLR", "drug_information": { "unit": "50.000000", "type": "UN" }, "code_information": [ { "code": "10511300102", "type": "NDC" } ], "standard_charges": [ { "minimum": 869.92, "maximum": 2901.78, "gross_charge": 3087.0, "discounted_cash": 1697.85, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1790.46, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1685.5, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2469.6, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2614.69, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 898.32, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1481.76, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1849.11, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 1846.03, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2901.78, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2716.56, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 869.92, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2623.95, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2315.25, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1087.55, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2099.16, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2901.78, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2417.12, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1685.5, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2454.17, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2315.25, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2716.56, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1790.46, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1685.5, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Hip arthr0 w/debridement", "code_information": [ { "code": "29862", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 5265.64, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3900.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 27281.99, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 49503.6, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5265.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 49503.6, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Hip arthr0 w/synovectomy", "code_information": [ { "code": "29863", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2391.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1771.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 20723.46, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 37603.05, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2391.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 37603.05, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Hip arthro acetabuloplasty", "code_information": [ { "code": "29915", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 5265.64, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3900.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 20019.53, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 36325.75, "methodology": "percent of total billed charges" }, { 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"N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 18161.05, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 32953.5, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5265.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 32953.5, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Hip arthro w/femoroplasty", "code_information": [ { "code": "29914", "type": "HCPCS" } ], "standard_charges": [ 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schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 36065.42, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Hip arthro w/labral repair", "code_information": [ { "code": "29916", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 5265.64, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3900.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 19876.05, "methodology": "percent of total billed charges" }, { "payer_name": 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"estimated_amount": 37216.13, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "HISTRELIN ACETATE (CPP) 50 MG SC KIT", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "67979000201", "type": "NDC" } ], "standard_charges": [ { "minimum": 11394.0, "maximum": 127405.32, "gross_charge": 135537.57, "discounted_cash": 74545.66, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 78611.79, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 24761.22, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 108430.06, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 114800.32, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39441.43, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 65058.03, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 81187.0, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": 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"methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 101653.18, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 47749.89, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 92165.55, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 127405.32, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": 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"payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 78611.79, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24761.22, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "HOMATROPINE HBR 5 % OP SOLN", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "59390019205", "type": "NDC" } ], "standard_charges": [ { "minimum": 12.17, "maximum": 40.61, "gross_charge": 43.2, "discounted_cash": 23.76, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.06, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.59, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.56, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.59, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.57, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.74, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.88, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.83, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.61, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.02, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.17, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.72, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.4, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.22, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.38, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.61, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.83, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.59, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.34, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.4, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.02, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.06, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.59, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "HPV 9-VALENT RECOMB VACCINE IM SUSY", "drug_information": { "unit": "0.500000", "type": "UN" }, "code_information": [ { "code": "00006412102", "type": "NDC" } ], "standard_charges": [ { "minimum": 314.12, "maximum": 1047.8, "gross_charge": 1114.68, "discounted_cash": 613.07, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 646.51, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 608.62, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 891.74, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 944.13, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 324.37, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 535.05, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 667.69, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 666.58, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1047.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 980.92, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 314.12, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 947.48, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 836.01, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 392.7, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 757.98, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1047.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 872.79, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 608.62, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 886.17, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 836.01, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 980.92, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 646.51, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 608.62, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "HYALURONAN 30 MG/2ML IX SOSY", "drug_information": { "unit": "2.000000", "type": "UN" }, "code_information": [ { "code": "59676036001", "type": "NDC" } ], "standard_charges": [ { "minimum": 522.64, "maximum": 1743.36, "gross_charge": 1854.64, "discounted_cash": 1020.05, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1075.69, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1012.63, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1483.71, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1570.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 539.7, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 890.23, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1110.93, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 1109.07, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1743.36, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1632.08, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 522.64, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1576.44, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1390.98, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 653.39, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1261.16, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1743.36, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1452.18, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1012.63, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1474.44, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1390.98, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1632.08, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1075.69, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1012.63, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "HYALURONAN 88 MG/4ML IX SOSY", "drug_information": { "unit": "4.000000", "type": "UN" }, "code_information": [ { "code": "59676082001", "type": "NDC" } ], "standard_charges": [ { "minimum": 373.01, "maximum": 3831.11, "gross_charge": 4075.65, "discounted_cash": 2241.61, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2363.88, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 373.01, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3260.52, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3452.08, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1186.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1956.31, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2441.31, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2437.24, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3831.11, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3586.57, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1148.52, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3464.3, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3056.74, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1435.85, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2771.44, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3831.11, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3191.23, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 503.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3240.14, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3056.74, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3586.57, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2363.88, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 373.01, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "HYALURONIDASE BOVINE 150 UNIT/ML IJ SOLN", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00548909010", "type": "NDC" } ], "standard_charges": [ { "minimum": 21.44, "maximum": 71.52, "gross_charge": 76.08, "discounted_cash": 41.84, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 44.13, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.54, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.86, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 64.44, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.14, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.52, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.57, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.5, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 71.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 66.95, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.44, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 64.67, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 57.06, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.8, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 51.73, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 71.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.57, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.54, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.48, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 57.06, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 66.95, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 44.13, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.54, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "HYALURONIDASE HUMAN 150 UNIT/ML IJ SOLN", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "18657011704", "type": "NDC" } ], "standard_charges": [ { "minimum": 25.69, "maximum": 85.71, "gross_charge": 91.18, "discounted_cash": 50.15, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.88, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.78, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 72.94, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 77.23, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.53, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.77, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.62, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.53, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 85.71, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 80.24, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.69, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 77.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 68.39, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.12, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 62.0, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 85.71, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 71.39, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.78, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 72.49, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 68.39, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 80.24, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.88, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.78, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "HYALURONIDASE INJ EXTRAVASATION SYRINGE 1", "drug_information": { "unit": "0.200000", "type": "UN" }, "code_information": [ { "code": "99888000053", "type": "NDC" } ], "standard_charges": [ { "minimum": 26.08, "maximum": 87.01, "gross_charge": 92.56, "discounted_cash": 50.91, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 53.68, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.54, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.05, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 78.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.93, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 44.43, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.44, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.35, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.01, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 81.45, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.08, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 78.68, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 69.42, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.61, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 62.94, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.01, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 72.47, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.54, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 73.59, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 69.42, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 81.45, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 53.68, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.54, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "HYDRALAZINE 2 MG/ML ORAL SUSPENSION", "drug_information": { "unit": "25.000000", "type": "UN" }, "code_information": [ { "code": "P5107907620", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "HYDRALAZINE HCL 10 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687081101", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "HYDRALAZINE HCL 100 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "R3172252201", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "HYDRALAZINE HCL 20 MG/ML IJ SOLN", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00641623125", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "HYDRALAZINE HCL 25 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "2315500201", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "HYDRALAZINE HCL 50 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "51079007620", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "HYDROCHLORIC ACID 1 NORMAL (FOR FEEDS)", "drug_information": { "unit": "0.500000", "type": "UN" }, "code_information": [ { "code": "P0825200001", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 1158.0, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.47, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "HYDROCHLOROTHIAZIDE 12.5 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687068301", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "HYDROCHLOROTHIAZIDE 25 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687059301", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "HYDROCHLOROTHIAZIDE 5 MG/ML ORAL SUSPENSION (PTL)", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "08252000218", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "HYDROCHLOROTHIAZIDE 50 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00172208960", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "HYDROCODONE-ACETAMINOPHEN 10-325 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687041801", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.25, "maximum": 7.52, "gross_charge": 8.0, "discounted_cash": 4.4, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.4, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.78, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.33, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.84, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.79, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.25, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.8, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.82, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.44, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.26, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.36, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "HYDROCODONE-ACETAMINOPHEN 5-325 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00406012362", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.25, "maximum": 7.52, "gross_charge": 8.0, "discounted_cash": 4.4, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.4, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.78, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.33, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.84, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.79, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.25, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.8, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.82, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.44, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.26, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.36, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "HYDROCORTISONE (PERIANAL) 2.5 % EX CREA", "drug_information": { "unit": "30.000000", "type": "GR" }, "code_information": [ { "code": "64980032430", "type": "NDC" } ], "standard_charges": [ { "minimum": 12.69, "maximum": 42.33, "gross_charge": 45.03, "discounted_cash": 24.77, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.12, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.59, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.02, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.14, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.1, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.61, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.97, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.93, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.33, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.63, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.69, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.28, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.77, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.86, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.62, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.33, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.26, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.59, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.77, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.63, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.12, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.59, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "HYDROCORTISONE 0.5 % EX CREA", "drug_information": { "unit": "29.000000", "type": "GR" }, "code_information": [ { "code": "51672201002", "type": "NDC" } ], "standard_charges": [ { "minimum": 3.25, "maximum": 10.86, "gross_charge": 11.55, "discounted_cash": 6.35, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.7, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.31, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.24, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.78, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.36, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.54, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.91, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.86, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.16, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.25, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.82, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.66, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.07, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.85, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.86, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.04, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.31, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.66, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.16, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.7, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.31, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "HYDROCORTISONE 1 % EX CREA", "drug_information": { "unit": "15.000000", "type": "GR" }, "code_information": [ { "code": "51672201301", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.38, "maximum": 7.94, "gross_charge": 8.45, "discounted_cash": 4.65, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.9, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.61, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.76, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.16, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.46, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.06, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.06, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.05, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.94, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.44, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.38, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.18, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.34, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.98, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.75, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.94, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.62, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.61, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.72, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.34, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.44, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.9, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.61, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "HYDROCORTISONE 1 % EX LOTN", "drug_information": { "unit": "114.000000", "type": "GR" }, "code_information": [ { "code": "00394085932", "type": "NDC" } ], "standard_charges": [ { "minimum": 4.63, "maximum": 15.44, "gross_charge": 16.43, "discounted_cash": 9.04, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.53, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.97, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.14, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.92, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.78, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.89, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.84, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.83, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.44, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.46, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.63, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.97, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.32, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.79, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.17, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.44, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.86, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.97, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.06, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.32, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.46, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.53, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.97, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "HYDROCORTISONE 1 % EX OINT", "drug_information": { "unit": "28.000000", "type": "GR" }, "code_information": [ { "code": "45802027603", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.35, "maximum": 4.49, "gross_charge": 4.78, "discounted_cash": 2.63, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.77, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.61, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.82, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.05, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.39, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.29, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.86, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.86, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.49, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.21, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.35, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.06, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.59, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.68, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.25, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.49, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.74, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.61, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.59, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.21, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.77, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.61, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "HYDROCORTISONE 10 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687058211", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "HYDROCORTISONE 100 MG/60ML RE ENEM", "drug_information": { "unit": "60.000000", "type": "UN" }, "code_information": [ { "code": "62559013807", "type": "NDC" } ], "standard_charges": [ { "minimum": 13.67, "maximum": 45.61, "gross_charge": 48.52, "discounted_cash": 26.69, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.14, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.49, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.82, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.1, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.12, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.29, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.06, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.01, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.61, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.7, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.67, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.24, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.39, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.99, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.61, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.99, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.49, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.57, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.39, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.7, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.14, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.49, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "HYDROCORTISONE 2 MG/ML ORAL SUSPENSION", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "00000000028", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "HYDROCORTISONE 2.5 % EX CREA", "drug_information": { "unit": "29.000000", "type": "GR" }, "code_information": [ { "code": "51672300302", "type": "NDC" } ], "standard_charges": [ { "minimum": 3.17, "maximum": 10.58, "gross_charge": 11.25, "discounted_cash": 6.19, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.53, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.14, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.53, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.27, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.4, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.74, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.73, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.58, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.9, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.17, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.56, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.44, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.96, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.65, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.58, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.81, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.14, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.94, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.44, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.9, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.53, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.14, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "HYDROCORTISONE 2.5 % EX OINT", "drug_information": { "unit": "20.000000", "type": "GR" }, "code_information": [ { "code": "45802001402", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.32, "maximum": 4.42, "gross_charge": 4.7, "discounted_cash": 2.59, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.73, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.98, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.37, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.26, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.82, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.81, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.42, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.14, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.32, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.53, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.66, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.42, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.68, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.74, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.53, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.14, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.73, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "HYDROCORTISONE 20 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "R5976200751", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "HYDROCORTISONE 5 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "50268040515", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "HYDROCORTISONE 50 MG/ML IV SYRINGE", "drug_information": { "unit": "2.000000", "type": "UN" }, "code_information": [ { "code": "00009001104", "type": "NDC" } ], "standard_charges": [ { "minimum": 13.67, "maximum": 45.59, "gross_charge": 48.5, "discounted_cash": 26.68, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.13, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.48, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.08, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.11, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.28, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.05, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.0, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.59, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.68, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.67, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.23, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.38, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.98, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.59, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.98, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.48, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.56, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.38, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.68, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.13, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.48, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "HYDROCORTISONE ACETATE 25 MG RE SUPP", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00713050324", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "HYDROCORTISONE ACETATE 30 MG RE SUPP", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00574709312", "type": "NDC" } ], "standard_charges": [ { "minimum": 8.78, "maximum": 29.3, "gross_charge": 31.17, "discounted_cash": 17.14, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.08, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.02, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.94, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.07, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.96, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.67, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.64, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.3, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.43, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.78, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.49, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.38, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.98, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.3, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.41, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.02, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.78, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.38, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.43, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.08, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.02, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "HYDROCORTISONE BUTYRATE 0.1 % EX CREA", "drug_information": { "unit": "45.000000", "type": "GR" }, "code_information": [ { "code": "51672407406", "type": "NDC" } ], "standard_charges": [ { "minimum": 46.44, "maximum": 154.91, "gross_charge": 164.8, "discounted_cash": 90.64, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 95.58, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 89.98, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 131.84, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 139.59, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.96, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 79.1, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 98.72, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 98.55, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 154.91, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 145.02, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.44, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 140.08, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 123.6, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 58.06, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 112.06, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 154.91, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 129.04, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 89.98, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 131.02, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 123.6, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 145.02, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 95.58, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 89.98, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "HYDROCORTISONE SOD SUC (PF) 100 MG IJ SOLR", "drug_information": { "unit": "2.000000", "type": "UN" }, "code_information": [ { "code": "00009001104_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 13.67, "maximum": 45.59, "gross_charge": 48.5, "discounted_cash": 26.68, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.13, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.48, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.08, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.11, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.28, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.05, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.0, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - 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"methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.98, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.59, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.98, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.48, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.56, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.38, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.68, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.13, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.48, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "HYDROCORTISONE SOD SUC (PF) 1000 MG IJ SOLR", "drug_information": { "unit": "8.000000", "type": "UN" }, "code_information": [ { "code": "00009000501", "type": "NDC" } ], "standard_charges": [ { "minimum": 141.43, "maximum": 471.76, "gross_charge": 501.87, "discounted_cash": 276.03, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 291.08, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 274.02, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 401.5, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 425.08, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 146.04, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 240.9, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 300.62, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 300.12, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 471.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 441.65, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 141.43, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 426.59, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 376.4, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 176.81, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 341.27, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 471.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 392.96, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 274.02, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 398.99, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 376.4, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 441.65, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 291.08, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 274.02, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "HYDROCORTISONE SOD SUC (PF) 250 MG IJ SOLR", "drug_information": { "unit": "250.000000", "type": "ME" }, "code_information": [ { "code": "00009001305", "type": "NDC" } ], "standard_charges": [ { "minimum": 25.14, "maximum": 83.85, "gross_charge": 89.2, "discounted_cash": 49.06, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 51.74, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 48.7, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 71.36, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.55, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.96, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.82, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 53.43, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 53.34, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 83.85, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 78.5, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.14, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.82, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 66.9, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.43, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.66, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 83.85, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 69.84, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 48.7, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 70.91, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 66.9, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 78.5, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 51.74, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 48.7, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "HYDROCORTISONE SOD SUC (PF) 500 MG IJ SOLR", "drug_information": { "unit": "4.000000", "type": "UN" }, "code_information": [ { "code": "00009001612", "type": "NDC" } ], "standard_charges": [ { "minimum": 60.54, "maximum": 201.94, "gross_charge": 214.83, "discounted_cash": 118.16, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 124.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 117.3, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 171.86, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 181.96, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 62.52, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.12, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 128.68, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 128.47, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 201.94, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 189.05, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.54, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 182.61, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 161.12, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.68, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 146.08, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 201.94, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 168.21, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 117.3, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 170.79, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 161.12, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 189.05, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 124.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 117.3, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "HYDROCORTISONE SOD SUCC 5 MG/ML SYRINGE (NICU)", "drug_information": { "unit": "20.000000", "type": "UN" }, "code_information": [ { "code": "08252000045", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "HYDROCORTISONE VALERATE 0.2 % EX CREA", "drug_information": { "unit": "60.000000", "type": "GR" }, "code_information": [ { "code": "51672129003", "type": "NDC" } ], "standard_charges": [ { "minimum": 37.78, "maximum": 126.04, "gross_charge": 134.08, "discounted_cash": 73.74, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 77.77, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 73.21, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 107.26, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 113.57, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.02, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 64.36, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 80.31, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 80.18, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 126.04, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 117.99, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.78, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 113.97, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 100.56, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.24, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 91.17, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 126.04, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 104.98, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 73.21, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 106.59, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 100.56, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 117.99, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 77.77, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 73.21, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "HYDROMORPHONE (PF) 10 MG/ML INTRATHECAL SYRINGE", "drug_information": { "unit": "20.000000", "type": "UN" }, "code_information": [ { "code": "00703011003", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.05, "maximum": 207.36, "gross_charge": 220.6, "discounted_cash": 121.33, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 127.95, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.05, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 176.48, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 186.85, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 64.19, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 105.89, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 132.14, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 131.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 207.36, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 194.13, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 62.17, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 187.51, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 165.45, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 77.72, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 150.01, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 207.36, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 172.73, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.07, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 175.38, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 165.45, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 194.13, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 127.95, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.05, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "HYDROMORPHONE 10 MG/50 ML PCA SYRINGE", "drug_information": { "unit": "50.000000", "type": "UN" }, "code_information": [ { "code": "70092111450_3", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "HYDROMORPHONE 10 MG/50 ML PCA SYRINGE (503B)(MULTI GPI)", "drug_information": { "unit": "50.000000", "type": "UN" }, "code_information": [ { "code": "70092111450_4", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "HYDROMORPHONE 30 MG/ML INJECTION", "drug_information": { "unit": "50.000000", "type": "UN" }, "code_information": [ { "code": "09990073620", "type": "NDC" } ], "standard_charges": [ { "minimum": 77.5, "maximum": 258.5, "gross_charge": 275.0, "discounted_cash": 151.25, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 159.5, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 150.15, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 220.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 232.93, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 80.03, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 132.0, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 164.73, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 164.45, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 258.5, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 242.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 77.5, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 233.75, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 206.25, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.88, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 187.0, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 258.5, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 215.33, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 150.15, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 218.63, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 206.25, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 242.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 159.5, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 150.15, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "HYDROMORPHONE 50 MG/50 ML PCA SYRINGE (503B)", "drug_information": { "unit": "50.000000", "type": "UN" }, "code_information": [ { "code": "70092111850_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "HYDROMORPHONE 500 MG/50 ML PCA SYRINGE (STRAIGHT DRUG)", "drug_information": { "unit": "50.000000", "type": "UN" }, "code_information": [ { "code": "08252000071", "type": "NDC" } ], "standard_charges": [ { "minimum": 85.06, "maximum": 283.74, "gross_charge": 301.85, "discounted_cash": 166.02, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 175.07, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 164.81, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 241.48, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 255.67, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.84, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 144.89, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 180.81, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 180.51, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 283.74, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 265.63, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 85.06, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 256.57, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 226.39, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 106.34, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 205.26, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 283.74, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 236.35, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 164.81, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 239.97, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 226.39, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 265.63, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 175.07, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 164.81, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "HYDROMORPHONE DRIP SYRINGE 0.2 MG/ML", "drug_information": { "unit": "50.000000", "type": "UN" }, "code_information": [ { "code": "70092111450", "type": "NDC" } ], "standard_charges": [ { "minimum": 12.68, "maximum": 42.3, "gross_charge": 45.0, "discounted_cash": 24.75, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.1, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.12, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.1, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.91, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.3, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.68, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.25, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.85, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.6, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.3, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.24, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.78, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.1, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "HYDROMORPHONE DRIP SYRINGE 0.2 MG/ML (MULTI GPI)", "drug_information": { "unit": "50.000000", "type": "UN" }, "code_information": [ { "code": "70092111450_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 12.68, "maximum": 42.3, "gross_charge": 45.0, "discounted_cash": 24.75, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.1, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.12, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.1, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.91, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.3, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.68, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.25, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.85, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.6, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.3, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.24, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.78, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.1, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "HYDROMORPHONE DRIP SYRINGE 1 MG/ML (503B)", "drug_information": { "unit": "50.000000", "type": "UN" }, "code_information": [ { "code": "70092111850_3", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "HYDROMORPHONE DRIP SYRINGE 1 MG/ML (MULTI GPI)", "drug_information": { "unit": "50.000000", "type": "UN" }, "code_information": [ { "code": "70092111850", "type": "NDC" } ], "standard_charges": [ { "minimum": 13.68, "maximum": 45.62, "gross_charge": 48.53, "discounted_cash": 26.69, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.15, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.5, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.82, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.1, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.12, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.29, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.07, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.02, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.62, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.71, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.68, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.25, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.4, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.1, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.0, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.62, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.0, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.5, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.58, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.4, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.71, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.15, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.5, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "HYDROMORPHONE HCL 0.2 MG/ML IV SOLN", "drug_information": { "unit": "50.000000", "type": "UN" }, "code_information": [ { "code": "73177010405", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "HYDROMORPHONE HCL 1 MG/ML IJ SOLN", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00409128331_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.05, "maximum": 42.3, "gross_charge": 45.0, "discounted_cash": 24.75, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.1, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.05, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.12, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.1, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.91, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.3, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.68, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.25, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.85, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.6, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.3, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.24, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.07, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.78, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.1, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.05, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "HYDROMORPHONE HCL 1 MG/ML IJ SOLN|DISCARDED DRUG NOT ADMINISTERED", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00409128331", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.05, "maximum": 3.96, "gross_charge": 4.21, "discounted_cash": 2.32, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.44, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.05, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.37, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.57, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.23, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.02, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.52, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.52, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.96, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.7, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.19, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.58, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.16, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.48, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.86, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.96, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.3, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.07, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.35, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.16, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.7, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.44, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.05, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "HYDROMORPHONE HCL 1 MG/ML PO LIQD", "drug_information": { "unit": "473.000000", "type": "UN" }, "code_information": [ { "code": "00054038663", "type": "NDC" } ], "standard_charges": [ { "minimum": 92.88, "maximum": 309.82, "gross_charge": 329.6, "discounted_cash": 181.28, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 191.17, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 179.96, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 263.68, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 279.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 95.91, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 158.21, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 197.43, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 197.1, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 309.82, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 290.05, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 92.88, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 280.16, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 247.2, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 116.12, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 224.13, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 309.82, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 258.08, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 179.96, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 262.03, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 247.2, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 290.05, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 191.17, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 179.96, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "HYDROMORPHONE HCL 2 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687057901", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.25, "maximum": 7.52, "gross_charge": 8.0, "discounted_cash": 4.4, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.4, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.78, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.33, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.84, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.79, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.25, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.8, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.82, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.44, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.26, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.36, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "HYDROMORPHONE HCL 2 MG/ML IJ SOLN", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00641615125_3", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.05, "maximum": 42.3, "gross_charge": 45.0, "discounted_cash": 24.75, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.1, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.05, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.12, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": 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"additional_payer_notes": "N/A", "standard_charge_dollar": 39.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.68, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.25, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.85, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.6, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.3, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.24, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.07, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.78, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.1, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.05, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "HYDROMORPHONE HCL 2 MG/ML IJ SOLN (MULTI-GPI)", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00641615125_4", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.05, "maximum": 42.3, "gross_charge": 45.0, "discounted_cash": 24.75, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.1, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.05, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.12, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.1, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.91, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.3, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.68, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.25, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.85, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.6, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.3, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.24, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.07, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.78, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.1, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.05, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "HYDROMORPHONE HCL 2 MG/ML IJ SOLN (MULTI-GPI)|DISCARDED DRUG NOT ADMINISTERED", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00641615125", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.05, "maximum": 1.43, "gross_charge": 1.52, "discounted_cash": 0.84, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.88, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.05, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.22, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.29, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.44, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.73, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.91, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.91, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.43, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.34, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.43, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.29, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.14, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.54, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.03, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.43, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.19, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.07, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.21, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.14, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.34, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.88, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.05, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "HYDROMORPHONE HCL 2 MG/ML IJ SOLN|DISCARDED DRUG NOT ADMINISTERED", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00641615125_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.05, "maximum": 1.43, "gross_charge": 1.52, "discounted_cash": 0.84, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.88, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.05, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.22, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.29, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.44, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.73, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.91, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.91, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.43, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.34, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.43, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.29, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.14, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.54, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.03, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.43, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.19, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.07, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.21, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.14, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.34, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.88, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.05, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "HYDROMORPHONE HCL 3 MG RE SUPP", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00574722406", "type": "NDC" } ], "standard_charges": [ { "minimum": 5.38, "maximum": 17.95, "gross_charge": 19.1, "discounted_cash": 10.51, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.08, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.43, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.28, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.18, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.56, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.17, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.44, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.42, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.95, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.81, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.38, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.24, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.33, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.73, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.99, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.95, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.96, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.43, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.33, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.81, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.08, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.43, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "HYDROMORPHONE HCL 4 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687059001", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.25, "maximum": 7.52, "gross_charge": 8.0, "discounted_cash": 4.4, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.4, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.78, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.33, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.84, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.79, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.25, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.8, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.82, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.44, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.26, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.36, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "HYDROMORPHONE HCL 4 MG/ML IJ SOLN", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00409130431_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.05, "maximum": 42.3, "gross_charge": 45.0, "discounted_cash": 24.75, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.1, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.05, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.12, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.1, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.91, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.3, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.68, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.25, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.85, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.6, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.3, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.24, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.07, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.78, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.1, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.05, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "HYDROMORPHONE HCL 4 MG/ML IJ SOLN|DISCARDED DRUG NOT ADMINISTERED", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00409130431", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.05, "maximum": 3.96, "gross_charge": 4.21, "discounted_cash": 2.32, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.44, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.05, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.37, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.57, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.23, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.02, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.52, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.52, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.96, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.7, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.19, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.58, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.16, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.48, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.86, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", 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"standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.68, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.25, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.85, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": 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"percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.1, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "HYDROMORPHONE HCL PF 10 MG/ML IJ SOLN|DISCARDED DRUG NOT ADMINISTERED", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "63323085115", "type": "NDC" } ], "standard_charges": [ { "minimum": 10.63, "maximum": 35.46, "gross_charge": 37.72, "discounted_cash": 20.75, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.88, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.6, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", 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"methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.29, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.65, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.46, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.53, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.6, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.99, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.29, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.19, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.88, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.6, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "HYDROMORPHONE HCL PF 2 MG/ML IJ SOLN", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "63323085325_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 12.68, "maximum": 42.3, "gross_charge": 45.0, "discounted_cash": 24.75, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.1, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.12, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.1, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.91, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.3, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.68, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.25, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.85, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.6, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.3, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.24, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.78, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.1, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "HYDROMORPHONE HCL PF 2 MG/ML IJ SOLN|DISCARDED DRUG NOT ADMINISTERED", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "63323085325", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.12, "maximum": 3.72, "gross_charge": 3.96, "discounted_cash": 2.18, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.3, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.16, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.17, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.35, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.15, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.9, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.37, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.37, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.72, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.48, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.12, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.37, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.97, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.4, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.69, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.72, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.1, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.16, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.15, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.97, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.48, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.3, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.16, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "HYDROMORPHONE HCL PF 50 MG/5ML IJ SOLN", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "63323085115_3", "type": "NDC" } ], "standard_charges": [ { "minimum": 12.68, "maximum": 42.3, "gross_charge": 45.0, "discounted_cash": 24.75, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.1, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.12, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.1, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.91, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.3, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.68, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.25, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.85, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.6, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.3, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.24, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.78, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.1, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "HYDROMORPHONE HCL PF 500 MG/50ML IJ SOLN", "drug_information": { "unit": "50.000000", "type": "UN" }, "code_information": [ { "code": "00409263450", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.05, "maximum": 260.62, "gross_charge": 277.25, "discounted_cash": 152.49, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 160.81, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.05, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 221.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 234.83, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 80.68, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 133.08, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 166.07, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 165.8, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 260.62, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 243.98, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 78.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 235.66, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 207.94, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 97.68, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 188.53, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 260.62, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 217.09, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.07, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 220.41, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 207.94, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 243.98, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 160.81, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.05, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "HYDROMORPHONE HCL-NACL 10-0.9 MG/50ML-% IV SOSY", "drug_information": { "unit": "50.000000", "type": "UN" }, "code_information": [ { "code": "70092111450_5", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "HYDROXOCOBALAMIN 5 G IV SOLR", "drug_information": { "unit": "200.000000", "type": "UN" }, "code_information": [ { "code": "50633031011", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.75, "maximum": 3398.63, "gross_charge": 3615.56, "discounted_cash": 1988.56, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2097.02, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.75, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2892.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3062.38, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1052.13, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1735.47, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2165.72, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2162.1, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3398.63, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3181.69, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1018.86, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3073.23, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2711.67, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1273.76, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2458.58, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3398.63, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2830.98, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.71, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2874.37, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2711.67, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3181.69, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2097.02, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.75, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "HYDROXOCOBALAMIN ACETATE 1000 MCG/ML IM SOLN", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00591288830_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": 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"methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "HYDROXOCOBALAMIN ACETATE 1000 MCG/ML IM SOLN|DISCARDED DRUG NOT ADMINISTERED", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00591288830", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.5, "maximum": 1.67, "gross_charge": 1.78, "discounted_cash": 0.98, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.03, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.97, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.42, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.51, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.52, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.85, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.07, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.06, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.67, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.57, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.5, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.51, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.34, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.63, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.21, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.67, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.39, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.97, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.42, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.34, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.57, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.03, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.97, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "HYDROXYCHLOROQUINE SULFATE 200 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68084026901", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "HYDROXYCHLOROQUINE SULFATE 25 MG/ML SUSPENSION", "drug_information": { "unit": "8.000000", "type": "UN" }, "code_information": [ { "code": "P0093977401", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "HYDROXYUREA 100 MG/ML SUSPENSION", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "00000999998", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": 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"Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "HYDROXYUREA 500 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68084028401", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "HYDROXYZINE HCL 10 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687066401", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "HYDROXYZINE HCL 10 MG/5ML PO SYRP", "drug_information": { "unit": "473.000000", "type": "UN" }, "code_information": [ { "code": "54838050280", "type": "NDC" } ], "standard_charges": [ { "minimum": 49.93, "maximum": 166.57, "gross_charge": 177.2, "discounted_cash": 97.46, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 102.78, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.75, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 141.76, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 150.09, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 51.57, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 85.06, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 106.14, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 105.97, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 166.57, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 155.94, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.93, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 150.62, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 132.9, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 62.43, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 120.5, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 166.57, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 138.75, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.75, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 140.87, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 132.9, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 155.94, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 102.78, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.75, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "HYDROXYZINE HCL 25 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687067501", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { 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"standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", 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"Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "HYDROXYZINE HCL 25 MG/ML IM SOLN", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00517420125", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.38, "maximum": 37.98, "gross_charge": 40.4, "discounted_cash": 22.22, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.43, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed 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charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.63, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.12, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.3, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.55, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.43, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "HYDROXYZINE HCL 50 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "1070201201", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, 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"HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "HYDROXYZINE HCL 50 MG/ML IM SOLN", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00517560125", "type": "NDC" } ], "standard_charges": [ { "minimum": 13.34, "maximum": 44.51, "gross_charge": 47.35, "discounted_cash": 26.04, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.46, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.85, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.88, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.11, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.78, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.73, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.36, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.32, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 44.51, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.67, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.34, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.25, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.51, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.68, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 44.51, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.08, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.85, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.64, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.51, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.67, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.46, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.85, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "HYDROXYZINE PAMOATE 25 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00185067405", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", 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billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "HYLAN G-F 20 16 MG/2ML IX SOSY", "drug_information": { "unit": "2.000000", "type": "UN" }, "code_information": [ { "code": "58468009001", "type": "NDC" } ], "standard_charges": [ { "minimum": 218.39, "maximum": 728.49, "gross_charge": 774.99, "discounted_cash": 426.24, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 449.49, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 423.14, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 619.99, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 656.42, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 225.52, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 372.0, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", 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"plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 658.74, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 581.24, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 273.03, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 526.99, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 728.49, 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"standard_charge_dollar": 681.99, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 449.49, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 423.14, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "HYLAN G-F 20 48 MG/6ML IX SOSY", "drug_information": { "unit": "6.000000", "type": "UN" }, "code_information": [ { "code": "58468009003", "type": "NDC" } ], "standard_charges": [ { "minimum": 5.0, "maximum": 2497.66, "gross_charge": 2657.08, "discounted_cash": 1461.39, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1541.11, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.0, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2125.66, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2250.55, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 773.21, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { 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"percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 748.77, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2258.52, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1992.81, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 936.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1806.81, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2497.66, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2080.49, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.75, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2112.38, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1992.81, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2338.23, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1541.11, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.0, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "Hymenotomy", "code_information": [ { "code": "56442", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2343.63, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1736.02, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 6476.76, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 12322.63, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2343.63, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 12322.63, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Hyoid myotomy & suspension", "code_information": [ { "code": "21685", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4360.43, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3229.95, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 24889.42, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 45521.17, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4360.43, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 45521.17, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "HYOSCYAMINE SULFATE 0.125 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "1327310803", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "HYOSCYAMINE SULFATE 0.125 MG PO TBDP", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "42192033801", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "HYOSCYAMINE SULFATE 0.125 MG SL SUBL", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "1327311103", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "HYOSCYAMINE SULFATE ER 0.375 MG PO TB12", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "47781001401", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "HYPROMELLOSE 0.3 % OP GEL", "drug_information": { "unit": "10.000000", "type": "GR" }, "code_information": [ { "code": "00065806401", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "HYPROMELLOSE 0.5 % OP SOLN", "drug_information": { "unit": "15.000000", "type": "UN" }, "code_information": [ { "code": "00065040872", "type": "NDC" } ], "standard_charges": [ { "minimum": 17.85, "maximum": 59.53, "gross_charge": 63.33, "discounted_cash": 34.83, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.73, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.58, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.66, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 53.64, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.43, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.4, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.93, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.87, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.53, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.73, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.85, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 53.83, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.31, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.06, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.53, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.59, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.58, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.35, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.73, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.73, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.58, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "HYPROMELLOSE 2.5 % OP SOLN", "drug_information": { "unit": "15.000000", "type": "UN" }, "code_information": [ { "code": "77790002215", "type": "NDC" } ], "standard_charges": [ { "minimum": 16.18, "maximum": 53.96, "gross_charge": 57.4, "discounted_cash": 31.57, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.29, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.34, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.92, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 48.62, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.7, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.55, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.38, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.33, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 53.96, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.51, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.18, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 48.79, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.05, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.22, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.03, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 53.96, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 44.94, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.34, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.63, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.05, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.51, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.29, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.34, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Hysteroscopy ablation", "code_information": [ { "code": "58563", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 3638.66, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2695.3, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 9993.54, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 18153.07, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3638.66, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 18153.07, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Hysteroscopy biopsy", "code_information": [ { "code": "58558", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2343.63, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1736.02, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 8458.16, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 15351.07, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2343.63, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 15351.07, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Hysteroscopy dx sep proc", "code_information": [ { "code": "58555", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2343.63, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1736.02, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 6721.79, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 12200.4, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2343.63, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 12200.4, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Hysteroscopy lysis", "code_information": [ { "code": "58559", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 3638.66, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2695.3, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 8200.38, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 14879.72, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3638.66, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 14879.72, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Hysteroscopy remove fb", "code_information": [ { "code": "58562", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2343.63, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1736.02, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 8539.64, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 15503.38, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2343.63, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 15503.38, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Hysteroscopy remove myoma", "code_information": [ { "code": "58561", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 3638.66, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2695.3, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 11115.18, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 20168.68, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3638.66, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 20168.68, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Hysteroscopy resect septum", "code_information": [ { "code": "58560", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 3638.66, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2695.3, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 9122.14, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 16831.27, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3638.66, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 16831.27, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "I & d of vulva/perineum", "code_information": [ { "code": "56405", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 224.22, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 971.66, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 1763.1, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 224.22, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 1763.1, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "IBANDRONATE SODIUM 150 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "55111057503", "type": "NDC" } ], "standard_charges": [ { "minimum": 9.04, "maximum": 30.16, "gross_charge": 32.08, "discounted_cash": 17.64, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.61, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.52, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.66, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.34, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.4, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.22, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.18, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.16, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.23, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.04, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.27, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.06, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.3, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.81, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.16, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.12, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.52, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.5, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.06, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.23, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.61, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.52, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "IBRUTINIB 140 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "57962014009", "type": "NDC" } ], "standard_charges": [ { "minimum": 192.46, "maximum": 642.0, "gross_charge": 682.98, "discounted_cash": 375.64, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 396.13, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 372.91, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 546.38, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 578.48, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 198.75, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 327.83, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 409.11, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 408.42, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 642.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 601.02, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 192.46, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 580.53, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 512.24, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 240.61, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 464.43, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 642.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 534.77, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 372.91, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 542.97, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 512.24, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 601.02, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 396.13, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 372.91, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "IBRUTINIB 420 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "57962042028", "type": "NDC" } ], "standard_charges": [ { "minimum": 659.88, "maximum": 2201.16, "gross_charge": 2341.66, "discounted_cash": 1287.91, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1358.16, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1278.55, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1873.33, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1983.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 681.42, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1124.0, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1402.65, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 1400.31, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2201.16, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2060.66, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 659.88, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1990.41, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1756.25, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 824.97, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1592.33, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2201.16, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1833.52, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1278.55, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1861.62, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1756.25, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2060.66, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1358.16, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1278.55, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "IBUPROFEN 100 MG/5ML PO SUSP", "drug_information": { "unit": "30.000000", "type": "UN" }, "code_information": [ { "code": "4580295226", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "IBUPROFEN 200 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00904791461", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "IBUPROFEN 400 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00904585361", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "IBUPROFEN 600 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687045701", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "IBUPROFEN 800 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00904585561", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "IBUPROFEN 800 MG/8ML IV SOLN", "drug_information": { "unit": "4.000000", "type": "UN" }, "code_information": [ { "code": "66220028708", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "IBUPROFEN LYSINE 10 MG/ML IV SOLN", "drug_information": { "unit": "2.000000", "type": "UN" }, "code_information": [ { "code": "55292012252", "type": "NDC" } ], "standard_charges": [ { "minimum": 572.05, "maximum": 1908.2, "gross_charge": 2030.0, "discounted_cash": 1116.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1177.4, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1108.38, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1762.04, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 590.73, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 974.4, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1215.97, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 1213.94, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1908.2, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1786.4, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 572.05, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1725.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1522.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 715.17, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1380.4, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1908.2, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1589.49, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1108.38, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1613.85, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1522.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1786.4, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1177.4, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1108.38, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ICAPS AREDS 2 PO CHEW", "drug_information": { "unit": "2.000000", "type": "UN" }, "code_information": [ { "code": "00658004803", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ICATIBANT ACETATE 30 MG/3ML SC SOSY", "drug_information": { "unit": "3.000000", "type": "UN" }, "code_information": [ { "code": "54092070202", "type": "NDC" } ], "standard_charges": [ { "minimum": 82.8, "maximum": 31435.92, "gross_charge": 33442.47, "discounted_cash": 18393.36, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 19396.63, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.8, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 26753.98, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 28325.77, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9731.76, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16052.39, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 20032.04, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 11394.0, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 31435.92, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 29429.37, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 9424.09, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 28426.1, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 25081.85, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11781.78, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 22740.88, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31435.92, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 26185.45, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 111.77, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 15189.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 25081.85, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 29429.37, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 19396.63, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.8, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "ICOSAPENT ETHYL 1 G PO CAPS", "drug_information": { "unit": "2.000000", "type": "UN" }, "code_information": [ { "code": "60505403301", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.2, "maximum": 4.0, "gross_charge": 4.26, "discounted_cash": 2.34, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.47, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.33, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.41, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.61, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.24, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.04, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.55, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.55, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.75, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.2, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.62, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.5, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.9, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.34, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.33, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.75, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.47, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.33, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "IDARUBICIN CHEMO SYRINGE", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "00143921801_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 55.09, "maximum": 183.77, "gross_charge": 195.5, "discounted_cash": 107.53, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 113.39, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 106.74, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 156.4, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 165.59, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 56.89, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.84, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 117.1, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 116.91, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 183.77, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 172.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.09, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 166.18, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 146.63, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 68.87, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 132.94, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 183.77, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 153.08, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 106.74, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 155.42, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 146.63, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 172.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 113.39, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 106.74, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "IDARUBICIN HCL 10 MG/10ML IV SOLN", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "00143921801", "type": "NDC" } ], "standard_charges": [ { "minimum": 42.44, "maximum": 141.56, "gross_charge": 150.6, "discounted_cash": 82.83, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.35, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.23, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 120.48, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 127.56, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.82, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 72.29, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 90.21, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 90.06, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 141.56, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 132.53, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.44, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 128.01, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 112.95, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 53.06, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 102.41, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 141.56, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 117.92, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.23, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 119.73, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 112.95, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 132.53, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.35, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.23, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "IDARUCIZUMAB 2.5 GM/50ML IV SOLN", "drug_information": { "unit": "50.000000", "type": "UN" }, "code_information": [ { "code": "00597019705", "type": "NDC" } ], "standard_charges": [ { "minimum": 2063.47, "maximum": 6883.1, "gross_charge": 7322.45, "discounted_cash": 4027.35, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4247.02, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3998.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5857.96, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6202.12, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2130.83, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3514.78, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4386.15, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4378.83, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6883.1, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6443.76, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2063.47, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6224.08, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5491.84, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2579.7, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4979.27, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6883.1, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5733.48, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3998.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5821.35, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5491.84, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6443.76, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4247.02, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3998.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "IDS ACTINIUM AC-225 DOTATATE", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00000999999", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.28, "maximum": 0.94, "gross_charge": 1.0, "discounted_cash": 0.55, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.58, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.55, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.85, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.29, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.6, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.6, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.94, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.88, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.28, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.85, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.35, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.68, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.94, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.78, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.55, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.88, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.58, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.55, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "IDS CLR I-131 THERAPEUTIC IV SOLUTION", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "08252000253", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.28, "maximum": 0.94, "gross_charge": 1.0, "discounted_cash": 0.55, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.58, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.55, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.85, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.29, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.6, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.6, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.94, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.88, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.28, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.85, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.35, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.68, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.94, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.78, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.55, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.88, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.58, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.55, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "IDS I131-1095 DIAGNOSTIC WHOLE BODY IV SOLN", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "08252000235", "type": "NDC" } ], "standard_charges": [ { "minimum": 36.77, "maximum": 122.67, "gross_charge": 130.5, "discounted_cash": 71.78, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.69, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 71.25, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 104.4, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 110.53, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.98, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 62.64, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 78.17, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 78.04, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 122.67, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 114.84, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.77, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 110.93, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 97.88, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.98, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.74, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 122.67, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 102.18, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 71.25, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.75, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 97.88, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 114.84, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.69, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 71.25, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "IDS I131-1095 PSMA IV SOLN", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "08252000237", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.82, "maximum": 9.4, "gross_charge": 10.0, "discounted_cash": 5.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.46, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.47, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.91, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.99, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.98, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.82, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.83, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.46, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.95, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.46, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "IDS I131-1095 THERAPEUTIC IV SOLN", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "08252000236", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.28, "maximum": 0.94, "gross_charge": 1.0, "discounted_cash": 0.55, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.58, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.55, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.85, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.29, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.6, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.6, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.94, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.88, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.28, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.85, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.35, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.68, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.94, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.78, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.55, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.88, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.58, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.55, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "IDS LUTETIUM LU-177 EDOTREOTIDE (177LU-DOTATOC)", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00000999983", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.28, "maximum": 0.94, "gross_charge": 1.0, "discounted_cash": 0.55, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.58, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.55, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.85, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.29, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.6, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.6, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.94, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.88, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.28, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.85, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.35, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.68, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.94, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.78, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.55, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.88, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.58, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.55, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "IDS LUTETIUM LU-177 PNT2002", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "08252000250", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.28, "maximum": 0.94, "gross_charge": 1.0, "discounted_cash": 0.55, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.58, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.55, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.85, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.29, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.6, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.6, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.94, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.88, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.28, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.85, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.35, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.68, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.94, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.78, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.55, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.88, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.58, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.55, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "IDS TECHNETIUM TC 99M PSMA I&S", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "08252000233", "type": "NDC" } ], "standard_charges": [ { "minimum": 468.07, "maximum": 1561.34, "gross_charge": 1661.0, "discounted_cash": 913.55, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 963.38, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 906.91, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1328.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1406.87, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 483.35, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 797.28, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 994.94, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 993.28, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1561.34, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1461.68, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 468.07, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1411.85, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1245.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 585.17, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1129.48, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1561.34, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1300.56, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 906.91, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1320.5, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1245.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1461.68, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 963.38, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 906.91, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "IDURSULFASE 6 MG/3ML IV SOLN", "drug_information": { "unit": "3.000000", "type": "UN" }, "code_information": [ { "code": "54092070001", "type": "NDC" } ], "standard_charges": [ { "minimum": 293.71, "maximum": 8098.02, "gross_charge": 8614.92, "discounted_cash": 4738.21, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4996.65, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 293.71, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6891.94, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7296.84, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2506.94, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4135.16, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5160.34, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 5151.72, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8098.02, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7581.13, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2427.68, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7322.68, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6461.19, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3035.04, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5858.15, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 8098.02, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6745.48, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 396.51, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6848.86, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6461.19, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7581.13, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4996.65, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 293.71, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "IFOSFAMIDE 1 G IV SOLR", "drug_information": { "unit": "20.000000", "type": "UN" }, "code_information": [ { "code": "10019092501", "type": "NDC" } ], "standard_charges": [ { "minimum": 18.54, "maximum": 61.83, "gross_charge": 65.78, "discounted_cash": 36.18, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.15, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.92, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.62, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.72, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.14, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.57, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.34, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.83, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 57.89, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.54, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.91, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.34, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.17, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 44.73, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.83, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 51.51, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.92, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.3, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.34, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 57.89, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.15, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.92, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "IFOSFAMIDE 1 GM/20ML IV SOLN", "drug_information": { "unit": "20.000000", "type": "UN" }, "code_information": [ { "code": "00143953101", "type": "NDC" } ], "standard_charges": [ { "minimum": 20.68, "maximum": 69.0, "gross_charge": 73.4, "discounted_cash": 40.37, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.57, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.08, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 58.72, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 62.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.36, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.23, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.97, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 69.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 64.59, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.68, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 62.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.05, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.86, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.91, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 69.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 57.47, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.08, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 58.35, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.05, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 64.59, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.57, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.08, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "IFOSFAMIDE 3 G IV SOLR", "drug_information": { "unit": "60.000000", "type": "UN" }, "code_information": [ { "code": "10019092602", "type": "NDC" } ], "standard_charges": [ { "minimum": 65.85, "maximum": 219.65, "gross_charge": 233.67, "discounted_cash": 128.52, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 135.53, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 127.58, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 186.94, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 197.92, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 68.0, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 112.16, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 139.97, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 139.73, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 219.65, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 205.63, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.85, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 198.62, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 175.25, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.32, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 158.9, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 219.65, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 182.96, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 127.58, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 185.77, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 175.25, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 205.63, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 135.53, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 127.58, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Iliac bone graft microvasc", "code_information": [ { "code": "20956", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 25336.31, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 45973.17, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 45973.17, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Iliac revasc", "code_information": [ { "code": "37220", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4202.59, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3113.03, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 21647.73, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 39280.17, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4202.59, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 39280.17, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Iliac revasc w/stent", "code_information": [ { "code": "37221", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 8359.13, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 6191.95, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 32599.84, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 59152.95, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8359.13, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 59152.95, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ILOPERIDONE 2 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "43068010202", "type": "NDC" } ], "standard_charges": [ { "minimum": 19.02, "maximum": 63.45, "gross_charge": 67.5, "discounted_cash": 37.13, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.15, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.86, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 57.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.4, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.43, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.37, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.45, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.4, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.02, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 57.38, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.63, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.78, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.9, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.45, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.85, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.86, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 53.66, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.63, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.4, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.15, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.86, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ILOPERIDONE 6 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "43068010602", "type": "NDC" } ], "standard_charges": [ { "minimum": 23.41, "maximum": 78.08, "gross_charge": 83.06, "discounted_cash": 45.68, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 48.17, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.35, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 66.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 70.35, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.17, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.87, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.75, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.67, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 78.08, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 73.09, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.41, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 70.6, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 62.3, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.26, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 56.48, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 78.08, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.04, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.35, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 66.03, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 62.3, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 73.09, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 48.17, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.35, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ILOPROST 10 MCG/ML IN SOLN", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "66215030230", "type": "NDC" } ], "standard_charges": [ { "minimum": 65.94, "maximum": 219.96, "gross_charge": 234.0, "discounted_cash": 128.7, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 135.72, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 127.76, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 187.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 198.2, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 68.09, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 112.32, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 140.17, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 139.93, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 219.96, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 205.92, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.94, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 198.9, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 175.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.44, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 159.12, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 219.96, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 183.22, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 127.76, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 186.03, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 175.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 205.92, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 135.72, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 127.76, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ILOPROST 20 MCG/ML IN SOLN", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "66215030330", "type": "NDC" } ], "standard_charges": [ { "minimum": 100.01, "maximum": 333.61, "gross_charge": 354.9, "discounted_cash": 195.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 205.84, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 193.78, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 283.92, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 300.6, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.28, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 170.35, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 212.59, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 212.23, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 333.61, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 312.31, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 100.01, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 301.67, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 266.18, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 125.03, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 241.33, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 333.61, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 277.89, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 193.78, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 282.15, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 266.18, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 312.31, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 205.84, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 193.78, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Image cath fluid colxn visc", "code_information": [ { "code": "49405", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1194.28, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 884.65, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 3549.88, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 6441.32, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1194.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 6441.32, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Image cath fluid peri/retro", "code_information": [ { "code": "49406", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1194.28, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 884.65, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 3437.59, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 6237.57, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1194.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 6237.57, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "IMATINIB 40 MG/ML ORAL SUSPENSION", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "08252000054", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.76, "maximum": 9.22, "gross_charge": 9.81, "discounted_cash": 5.4, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.69, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.36, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.85, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.31, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.85, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.71, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.88, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.87, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.22, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.63, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.76, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.34, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.36, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.46, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.67, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.22, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.68, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.36, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.36, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.63, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.69, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.36, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "IMATINIB MESYLATE 100 MG PO TABS", "drug_information": { "unit": "4.000000", "type": "UN" }, "code_information": [ { "code": "60687019221", "type": "NDC" } ], "standard_charges": [ { "minimum": 6.29, "maximum": 20.98, "gross_charge": 22.32, "discounted_cash": 12.28, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.95, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.19, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.86, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.91, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.5, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.71, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.37, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.35, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.98, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.64, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.29, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.97, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.74, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.86, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.18, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.98, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.48, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.19, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.74, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.74, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.64, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.95, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.19, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "IMATINIB MESYLATE 400 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "59651024130", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "IMETELSTAT SODIUM 188 MG IV SOLR", "drug_information": { "unit": "6.000000", "type": "UN" }, "code_information": [ { "code": "82959011101", "type": "NDC" } ], "standard_charges": [ { "minimum": 29.57, "maximum": 27872.88, "gross_charge": 29652.0, "discounted_cash": 16308.6, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 17198.16, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.57, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23721.6, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 25115.24, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8628.73, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14232.96, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 17761.55, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 11394.0, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 27872.88, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 26093.76, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 8355.93, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 25204.2, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 22239.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 10446.4, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 20163.36, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27872.88, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23217.52, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.91, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 15189.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 22239.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 26093.76, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 17198.16, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.57, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "IMETELSTAT SODIUM 47 MG IV SOLR", "drug_information": { "unit": "1.500000", "type": "UN" }, "code_information": [ { "code": "82959011201", "type": "NDC" } ], "standard_charges": [ { "minimum": 2088.98, "maximum": 6968.22, "gross_charge": 7413.0, "discounted_cash": 4077.15, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4299.54, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4047.5, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5930.4, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6278.81, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2157.18, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3558.24, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4440.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4432.97, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6968.22, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6523.44, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2088.98, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6301.05, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5559.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2611.6, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5040.84, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6968.22, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5804.38, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4047.5, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5893.34, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5559.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6523.44, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4299.54, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4047.5, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Img gid flu coll drg sft tis", "code_information": [ { "code": "10030", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 518.62, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 384.16, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 1878.19, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 3408.01, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 518.62, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 3408.01, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "IMIGLUCERASE 400 UNITS IV SOLR", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "58468466301", "type": "NDC" } ], "standard_charges": [ { "minimum": 1451.52, "maximum": 4841.83, "gross_charge": 5150.88, "discounted_cash": 2832.98, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2987.51, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2812.38, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4120.7, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { 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"standard_charge_dollar": 3863.16, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1814.66, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3502.6, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4841.83, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4033.14, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2812.38, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4094.95, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3863.16, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4532.77, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2987.51, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2812.38, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "IMIPENEM-CILASTATIN 500 MG IV SOLR", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "63323032225", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "IMIPENEM-CILASTATIN-RELEBACTAM 1.25 G IV SOLR", "drug_information": { "unit": "20.000000", "type": "UN" }, "code_information": [ { "code": "00006385602", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.37, "maximum": 1045.22, "gross_charge": 1111.94, "discounted_cash": 611.57, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 644.93, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.37, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 889.55, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 941.81, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 323.57, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 533.73, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 666.05, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 664.94, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1045.22, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 978.51, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 313.34, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 945.15, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 833.96, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 391.74, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 756.12, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1045.22, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 870.65, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.85, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 883.99, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 833.96, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 978.51, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 644.93, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.37, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "IMIPRAMINE HCL 10 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "4229134501", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "IMIPRAMINE HCL 25 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "R6931513401", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "IMIPRAMINE HCL 50 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "4229134701", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "IMIQUIMOD 2.5 % EX CREA", "drug_information": { "unit": "7.500000", "type": "GR" }, "code_information": [ { "code": "99207027675", "type": "NDC" } ], "standard_charges": [ { "minimum": 1100.68, "maximum": 3671.55, "gross_charge": 3905.9, "discounted_cash": 2148.25, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2265.42, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2132.62, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3124.72, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3308.3, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1136.62, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1874.83, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2339.63, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2335.73, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3671.55, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3437.19, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1100.68, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3320.02, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2929.43, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1376.05, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2656.01, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3671.55, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3058.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2132.62, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3105.19, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2929.43, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3437.19, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2265.42, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2132.62, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "IMIQUIMOD 5 % EX CREA", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "45802036862", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "IMMUNE GLOBULIN (GAMUNEX) 5 G/50 ML IV SOLN (NICU)(=100", "code_information": [ { "code": "69729", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 9484.13, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 7025.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 25914.03, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 47021.4, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 9484.13, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 47021.4, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Impl oi implt skull perq esp", "code_information": [ { "code": "69714", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 9484.13, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 7025.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 25801.24, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 46816.75, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 9484.13, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 46816.75, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Implant cochlear device", "code_information": [ { "code": "69930", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 23445.54, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 17367.07, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 69864.68, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 126770.58, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23445.54, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 126770.58, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Implant eye drug system", "code_information": [ { "code": "67027", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 51520.03, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 93483.9, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 93483.9, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Implant hormone pellet(s)", "code_information": [ { "code": "11980", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 294.13, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 217.88, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 5402.38, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 9802.7, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 294.13, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 9802.7, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Implant neuroelectrodes", "code_information": [ { "code": "63650", "type": "HCPCS" }, { "code": "63655", "type": "HCPCS" }, { "code": "64553", "type": "HCPCS" }, { "code": "64555", "type": "HCPCS" }, { "code": "64561", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 15806.66, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3583.34, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 11708.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 6808.79, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 17079.68, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 31037.21, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4837.51, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 15806.66, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 9191.87, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 31037.21, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Implant neurostim arrays", "code_information": [ { "code": "61886", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 22462.08, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 16638.58, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 46391.35, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 84177.86, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 22462.08, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 84177.86, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Implant spinal canal cath", "code_information": [ { "code": "62350", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4720.44, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3496.62, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 36279.99, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 66487.84, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4720.44, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 66487.84, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Implant spine infusion pump", "code_information": [ { "code": "62362", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 13027.59, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 9650.07, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 31927.01, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 57932.07, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 13027.59, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 57932.07, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Implant tcat pulm vlv perq", "code_information": [ { "code": "33477", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 94043.87, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 170644.12, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 170644.12, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Incise & drain bladder", "code_information": [ { "code": "51040", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1509.96, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1118.49, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 7103.22, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 12888.9, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1509.96, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 12888.9, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Incise finger tendon sheath", "code_information": [ { "code": "26055", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1179.66, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 873.82, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 4629.16, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 8399.7, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1179.66, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 8399.7, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Incise hand/finger tendon", "code_information": [ { "code": "26460", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1179.66, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 873.82, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 15271.4, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 27710.21, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1179.66, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 27710.21, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Incise inner eye adhesions", "code_information": [ { "code": "65860", "type": "HCPCS" }, { "code": "65865", "type": "HCPCS" }, { "code": "65870", "type": "HCPCS" }, { "code": "65875", "type": "HCPCS" }, { "code": "65880", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2965.25, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 299.54, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1245.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2196.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 1081.76, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 1962.89, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 404.37, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1681.13, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2965.25, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 1962.89, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Incise nerve back of head", "code_information": [ { "code": "64744", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1439.39, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1066.21, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 26525.09, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 48144.55, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1439.39, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 48144.55, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Incise skull/brain biopsy", "code_information": [ { "code": "61750", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 29147.22, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 52888.18, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 52888.18, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Incise skull/brain surgery", "code_information": [ { "code": "61720", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4720.44, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3496.62, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 6589.6, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 11956.94, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4720.44, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 11956.94, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Incise tear duct opening", "code_information": [ { "code": "68440", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 220.34, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 163.22, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 4283.55, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 7772.56, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 220.34, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 7772.56, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Incise thigh tendon & fascia", "code_information": [ { "code": "27305", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2391.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1771.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 14822.96, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 26896.5, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2391.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 26896.5, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Incise wrist/forearm tendon", "code_information": [ { "code": "25290", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2391.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1771.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 10101.02, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 18965.97, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2391.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 18965.97, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Incise/drain eyelid lining", "code_information": [ { "code": "68020", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 713.91, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 528.82, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 8120.02, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 14733.91, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 713.91, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 14733.91, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Incise/graft midfoot bones", "code_information": [ { "code": "28305", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 5265.64, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3900.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 39656.79, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 71957.94, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5265.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 71957.94, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Incision of achilles tendon", "code_information": [ { "code": "27606", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2391.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1771.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 32605.36, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 59162.96, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2391.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 59162.96, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Incision of anal abscess", "code_information": [ { "code": "46050", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 672.02, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 1914.56, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 3474.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 672.02, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 3474.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Incision of anal sphincter", "code_information": [ { "code": "46080", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2021.42, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1497.34, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 5136.07, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 9323.1, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2021.42, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 9323.1, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Incision of burn scab initi", "code_information": [ { "code": "16035", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 294.49, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 218.14, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 17516.84, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 32003.67, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 294.49, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 32003.67, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Incision of eardrum", "code_information": [ { "code": "69421", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2390.47, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1770.72, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 28233.53, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 51230.15, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2390.47, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 51230.15, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Incision of eye", "code_information": [ { "code": "65850", "type": "HCPCS" }, { "code": "66172", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1681.13, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1245.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 7304.89, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 13254.86, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1681.13, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 13254.86, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Incision of eyelid", "code_information": [ { "code": "67710", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 713.91, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 528.82, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 4716.98, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 8667.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 713.91, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 8667.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Incision of eyelid fold", "code_information": [ { "code": "67715", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1719.62, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1273.8, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 9276.06, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 16831.56, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1719.62, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 16831.56, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Incision of facial nerve", "code_information": [ { "code": "64742", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1439.39, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1066.21, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 6153.47, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 11165.56, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1439.39, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 11165.56, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Incision of foot fascia", "code_information": [ { "code": "28008", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2391.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1771.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 7541.43, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 13684.04, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2391.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 13684.04, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Incision of foot tendon", "code_information": [ { "code": "28234", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1179.66, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 873.82, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 12848.85, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 23314.54, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1179.66, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 23314.54, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Incision of foot tendon(s)", "code_information": [ { "code": "28230", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1179.66, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 873.82, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 12848.85, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 23314.54, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1179.66, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 23314.54, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Incision of gallbladder", "code_information": [ { "code": "47490", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2601.27, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1926.87, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 2976.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 5400.01, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2601.27, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 5400.01, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Incision of heel bone", "code_information": [ { "code": "28300", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 5265.64, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3900.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 13278.29, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 24093.68, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5265.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 24093.68, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Incision of hip tendon", "code_information": [ { "code": "27000", "type": "HCPCS" }, { "code": "27001", "type": "HCPCS" }, { "code": "27005", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2391.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 873.82, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1771.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 14053.23, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 25507.04, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1179.66, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2391.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 25507.04, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Incision of hip tendons", "code_information": [ { "code": "27006", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2391.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1771.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 7343.28, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 13324.5, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2391.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 13324.5, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Incision of hip/thigh fascia", "code_information": [ { "code": "27025", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 17616.89, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 31966.18, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 31966.18, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Incision of iris", "code_information": [ { "code": "66500", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1681.13, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1245.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 8312.87, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 15083.83, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1681.13, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 15083.83, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Incision of jaw joint", "code_information": [ { "code": "21010", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2390.47, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1770.72, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 14881.43, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 27337.12, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2390.47, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 27337.12, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Incision of jaw nerve", "code_information": [ { "code": "64738", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1439.39, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1066.21, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 15454.11, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 28041.75, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1439.39, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 28041.75, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Incision of knee joint", "code_information": [ { "code": "27435", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2391.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1771.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 37032.42, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 67195.94, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2391.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 67195.94, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Incision of metatarsal", "code_information": [ { "code": "28306", "type": "HCPCS" }, { "code": "28308", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 5265.64, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3900.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1771.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 19609.58, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 35581.9, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5265.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2391.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 35581.9, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Incision of metatarsals", "code_information": [ { "code": "28309", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 5265.64, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3900.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 14065.02, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 25521.21, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5265.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 25521.21, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Incision of midfoot bones", "code_information": [ { "code": "28304", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 5265.64, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3900.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 25995.15, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 47168.66, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5265.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 47168.66, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Incision of prostate", "code_information": [ { "code": "52450", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2542.24, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1883.14, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 7831.84, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 14211.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2542.24, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 14211.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Incision of rectal abscess", "code_information": [ { "code": "46045", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2021.42, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1497.34, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 6919.48, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 12555.52, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2021.42, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 12555.52, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Incision of spinal nerve", "code_information": [ { "code": "64772", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1439.39, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1066.21, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 11599.07, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 21046.69, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1439.39, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 21046.69, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Incision of tendon & muscle", "code_information": [ { "code": "23405", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 5265.64, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3900.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 19627.27, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 35614.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5265.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 35614.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Incision of tendon sheath", "code_information": [ { "code": "25000", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1179.66, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 873.82, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 5584.96, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 10134.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1179.66, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 10134.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Incision of thigh", "code_information": [ { "code": "27450", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 31309.82, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 56812.21, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 56812.21, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Incision of tibia", "code_information": [ { "code": "27705", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 5265.64, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3900.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 20816.34, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 37771.6, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5265.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 37771.6, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Incision of tibia & fibula", "code_information": [ { "code": "27709", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 9484.13, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 7025.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 18608.18, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 33764.82, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 9484.13, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 33764.82, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Incision of toe tendon", "code_information": [ { "code": "28010", "type": "HCPCS" }, { "code": "28232", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1179.66, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 873.82, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 13382.14, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 24282.11, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1179.66, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 24282.11, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Incision of tongue fold", "code_information": [ { "code": "41010", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1091.85, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 808.78, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 23128.98, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 42171.39, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1091.85, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 42171.39, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Incision of tongue nerve", "code_information": [ { "code": "64740", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1439.39, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1066.21, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 36738.68, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 66662.93, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1439.39, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 66662.93, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Incision of urethra", "code_information": [ { "code": "53010", "type": "HCPCS" }, { "code": "53020", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 3747.14, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2775.66, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1118.49, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 19920.25, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, 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"additional_generic_notes": "" } ] }, { "description": "INCLISIRAN SODIUM 284 MG/1.5ML SC SOSY", "drug_information": { "unit": "1.500000", "type": "UN" }, "code_information": [ { "code": "00078100060", "type": "NDC" } ], "standard_charges": [ { "minimum": 2887.53, "maximum": 9631.94, "gross_charge": 10246.74, "discounted_cash": 5635.71, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5943.11, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5594.72, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8197.39, 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Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7685.06, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3609.93, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6967.78, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 9631.94, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8023.2, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5594.72, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 8146.16, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7685.06, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9017.13, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5943.11, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5594.72, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "INCOBOTULINUMTOXINA 100 UNITS IM SOLR", "drug_information": { "unit": "100.000000", "type": "UN" }, "code_information": [ { "code": "00259161001", "type": "NDC" } ], "standard_charges": [ { "minimum": 576.0, "maximum": 1921.36, "gross_charge": 2044.0, "discounted_cash": 1124.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1185.52, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1116.02, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1635.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1731.27, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 594.8, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 981.12, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1224.36, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 1222.31, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1921.36, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1798.72, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 576.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1737.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1533.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 720.1, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1389.92, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1921.36, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1600.45, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1116.02, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1624.98, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1533.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1798.72, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1185.52, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1116.02, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "INCOBOTULINUMTOXINA 50 UNITS IM SOLR", "drug_information": { "unit": "50.000000", "type": "UN" }, "code_information": [ { "code": "00259160501", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.92, "maximum": 1007.68, "gross_charge": 1072.0, "discounted_cash": 589.6, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 621.76, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.92, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 857.6, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 907.98, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 311.95, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 514.56, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 642.13, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 641.06, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1007.68, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 943.36, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 302.09, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 911.2, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 804.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 377.67, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 728.96, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1007.68, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 839.38, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.94, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", 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"INDIGOTINDISULFONATE SODIUM 8 MG/ML IV SOLN", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "81284031505", "type": "NDC" } ], "standard_charges": [ { "minimum": 347.11, "maximum": 1158.0, "gross_charge": 1231.75, "discounted_cash": 677.46, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 714.42, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 672.54, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": 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charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1157.85, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1083.94, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 347.11, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1046.99, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 923.81, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 433.95, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 837.59, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1157.85, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 964.46, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 672.54, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 979.24, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 923.81, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1083.94, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 714.42, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 672.54, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "INDIUM IN 111 DTPA IT SOLN", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "17156025108", "type": "NDC" } ], "standard_charges": [ { "minimum": 390.55, "maximum": 6613.61, "gross_charge": 7035.75, "discounted_cash": 3869.66, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4080.74, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 390.55, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5628.6, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5959.28, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2047.4, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3377.16, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4214.41, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4207.38, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6613.61, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6191.46, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1982.67, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5980.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5276.81, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2478.69, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4784.31, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6613.61, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5508.99, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 527.24, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5593.42, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5276.81, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6191.46, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4080.74, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 390.55, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "INDIUM IN-111 PENTETREOTIDE IV KIT", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00019905040", "type": "NDC" } ], "standard_charges": [ { "minimum": 1045.38, "maximum": 14082.38, "gross_charge": 14981.25, "discounted_cash": 8239.69, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 8689.13, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1045.38, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11985.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12689.12, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4359.54, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7191.0, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 8973.77, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 8958.79, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14082.38, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13183.5, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 4221.72, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12734.06, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11235.94, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 5277.89, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 10187.25, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 14082.38, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 11730.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1411.26, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 11910.09, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11235.94, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13183.5, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8689.13, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1045.38, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "INDIUM IN-111 WBC", "drug_information": { "unit": "6.000000", "type": "UN" }, "code_information": [ { "code": "04444113707", "type": "NDC" } ], "standard_charges": [ { "minimum": 9943.17, "maximum": 33167.43, "gross_charge": 35284.5, "discounted_cash": 19406.48, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 20465.01, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 19265.34, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 28227.6, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 29885.97, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10267.79, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16936.56, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 21135.42, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 11394.0, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33167.43, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 31050.36, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 9943.17, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 29991.83, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 26463.38, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 12430.73, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23993.46, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 33167.43, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 27627.76, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 19265.34, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 15189.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 26463.38, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 31050.36, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 20465.01, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 19265.34, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "INDOCYANINE GREEN 25 MG IV SOLR", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "70100042402", "type": "NDC" } ], "standard_charges": [ { "minimum": 141.77, "maximum": 1158.0, "gross_charge": 503.08, "discounted_cash": 276.69, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 291.79, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 274.68, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 436.67, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 146.4, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 241.48, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 301.34, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 300.84, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 472.9, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 442.71, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 141.77, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 427.62, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 377.31, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 177.24, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 342.09, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 472.9, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 393.91, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 274.68, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 399.95, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 377.31, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 442.71, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 291.79, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 274.68, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "INDOMETHACIN 25 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "50268043015", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "INDOMETHACIN 25 MG/5ML PO SUSP", "drug_information": { "unit": "237.000000", "type": "UN" }, "code_information": [ { "code": "69344010101", "type": "NDC" } ], "standard_charges": [ { "minimum": 1510.93, "maximum": 5040.0, "gross_charge": 5361.7, "discounted_cash": 2948.94, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3109.79, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2927.49, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4289.36, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4541.36, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1560.25, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2573.62, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3211.66, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 3206.3, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5040.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4718.3, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1510.93, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4557.45, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4021.28, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1888.93, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3645.96, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5040.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4198.21, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2927.49, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4262.55, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4021.28, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4718.3, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3109.79, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2927.49, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "INDOMETHACIN 50 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "50268043115", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "INDOMETHACIN 50 MG RE SUPP", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "69344010233", "type": "NDC" } ], "standard_charges": [ { "minimum": 178.47, "maximum": 595.33, "gross_charge": 633.33, "discounted_cash": 348.33, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 367.33, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 345.8, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 506.66, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 536.43, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 184.3, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 304.0, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 379.36, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 378.73, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 595.33, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 557.33, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 178.47, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 538.33, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 475.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 223.12, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 430.66, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 595.33, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 495.9, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 345.8, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 503.5, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 475.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 557.33, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 367.33, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 345.8, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "INDOMETHACIN ER 75 MG PO CPCR", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68084041121", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "INDOMETHACIN SODIUM 1 MG IV SOLR", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "63323065903", "type": "NDC" } ], "standard_charges": [ { "minimum": 296.06, "maximum": 1158.0, "gross_charge": 1050.6, "discounted_cash": 577.83, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 609.35, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 573.63, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 911.92, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 305.72, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 504.29, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 629.31, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 628.26, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 987.56, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 924.53, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 296.06, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 893.01, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 787.95, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 370.13, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 714.41, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 987.56, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 822.62, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 573.63, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 835.23, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 787.95, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 924.53, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 609.35, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 573.63, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "INFLIXIMAB 100 MG IV SOLR", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "57894003001", "type": "NDC" } ], "standard_charges": [ { "minimum": 17.59, "maximum": 3192.89, "gross_charge": 3396.69, "discounted_cash": 1868.18, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1970.08, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.59, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2717.35, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2877.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 988.44, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1630.41, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2034.62, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2031.22, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3192.89, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2989.09, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 957.19, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2887.19, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2547.52, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1196.65, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2309.75, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3192.89, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2659.61, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.75, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2700.37, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2547.52, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2989.09, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1970.08, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.59, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "INFLIXIMAB-ABDA 100 MG IV SOLR", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "78206016201", "type": "NDC" } ], "standard_charges": [ { "minimum": 14.84, "maximum": 1536.49, "gross_charge": 1634.56, "discounted_cash": 899.01, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 948.04, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.84, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1307.65, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1384.47, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 475.66, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 784.59, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 979.1, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 977.47, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1536.49, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1438.41, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 460.62, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1389.38, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1225.92, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 575.86, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1111.5, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1536.49, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1279.86, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.03, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1299.48, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1225.92, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1438.41, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 948.04, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.84, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "INFLIXIMAB-DYYB 100 MG IV SOLR", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "00069080901", "type": "NDC" } ], "standard_charges": [ { "minimum": 7.44, "maximum": 2126.32, "gross_charge": 2262.04, "discounted_cash": 1244.12, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1311.98, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.44, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1809.63, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1915.95, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 658.25, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1085.78, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1354.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 1352.7, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2126.32, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1990.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 637.44, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1922.73, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1696.53, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 796.92, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1538.19, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2126.32, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1771.18, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.04, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1798.32, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1696.53, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1990.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1311.98, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.44, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "INFLUENZA VAC SPLIT HIGH-DOSE 0.5 ML IM SUSY", "drug_information": { "unit": "0.500000", "type": "UN" }, "code_information": [ { "code": "49281012465", "type": "NDC" } ], "standard_charges": [ { "minimum": 49.83, "maximum": 166.22, "gross_charge": 176.83, "discounted_cash": 97.26, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 102.56, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.55, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 141.46, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 149.78, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 51.46, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 84.88, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 105.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 105.74, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 166.22, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 155.61, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.83, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 150.31, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 132.62, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 62.3, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 120.24, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 166.22, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 138.46, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.55, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 140.58, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 132.62, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 155.61, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 102.56, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.55, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "INFLUENZA VACCINE QUADRIVALENT PF SYR (FLUARIX QUAD)", "drug_information": { "unit": "0.500000", "type": "UN" }, "code_information": [ { "code": "58160090952", "type": "NDC" } ], "standard_charges": [ { "minimum": 13.9, "maximum": 46.37, "gross_charge": 49.33, "discounted_cash": 27.13, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.61, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.93, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.46, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.78, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.36, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.68, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.55, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.5, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.37, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.41, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.9, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.93, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.38, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.54, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.37, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.63, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.93, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.22, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.41, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.61, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.93, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "INFLUENZA VACCINE TRIVALENT PF SYR (FLUARIX)", "drug_information": { "unit": "0.500000", "type": "UN" }, "code_information": [ { "code": "58160088452", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "INFLUENZA VIRUS VACC SPLIT PF 0.5 ML IM SUSY", "drug_information": { "unit": "0.500000", "type": "UN" }, "code_information": [ { "code": "49281042450", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.39, "maximum": 37.99, "gross_charge": 40.42, "discounted_cash": 22.23, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.44, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.07, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.34, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.24, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.76, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.4, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.21, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.17, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.99, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.57, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.39, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.36, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.32, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.24, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.49, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.99, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.65, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.07, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.13, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.32, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.57, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.44, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.07, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Infratemporal approach/skull", "code_information": [ { "code": "61590", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 39289.38, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 71494.71, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 71494.71, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "INFUVITE ADULT IV INJ", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "54643564901", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 1158.0, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.72, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "INFUVITE PEDIATRIC IV SOLN", "drug_information": { "unit": "50.000000", "type": "UN" }, "code_information": [ { "code": "54643564700_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 131.24, "maximum": 1158.0, "gross_charge": 465.71, "discounted_cash": 256.14, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 270.11, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 254.28, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 404.24, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 135.52, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 223.54, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 278.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 278.49, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 437.77, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 409.82, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 131.24, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 395.85, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 349.28, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 164.07, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 316.68, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 437.77, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 364.65, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 254.28, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 370.24, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 349.28, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 409.82, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 270.11, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 254.28, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Inj dupuytren cord w/enzyme", "code_information": [ { "code": "20527", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 217.58, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 161.17, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 4019.58, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 7293.6, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 217.58, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 7293.6, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Inj for sacroiliac jt anesth", "code_information": [ { "code": "G0260", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 510.46, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 378.12, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 2028.64, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 3681.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 510.46, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 3681.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Inj paravert f jnt c/t 1 lev", "code_information": [ { "code": "64490", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 656.23, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 486.1, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 2372.88, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 4305.63, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 656.23, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 4305.63, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Inj paravert f jnt l/s 1 lev", "code_information": [ { "code": "64493", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 656.23, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 486.1, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 2068.32, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 3753.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 656.23, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 3753.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Inj tendon origin/insertion", "code_information": [ { "code": "20551", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 217.58, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 161.17, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 2109.71, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 3828.11, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 217.58, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 3828.11, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Inj tendon sheath/ligament", "code_information": [ { "code": "20550", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 217.58, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 1716.14, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 3114.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 217.58, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 3114.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Inj trigger point 1/2 muscl", "code_information": [ { "code": "20552", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 217.58, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 161.17, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 1733.04, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 3144.63, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 217.58, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 3144.63, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Inj w/fluor eval cv device", "code_information": [ { "code": "36598", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 155.3, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 115.04, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 4533.44, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 8226.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 155.3, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 8226.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Inject epidural patch", "code_information": [ { "code": "62273", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 510.46, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 378.12, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 3224.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 5850.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 510.46, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 5850.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Inject for lymphatic x-ray", "code_information": [ { "code": "38790", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 18971.16, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 34423.49, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 34423.49, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Inject sacroiliac joint", "code_information": [ { "code": "27096", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 1732.75, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 3144.11, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 3144.11, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Inject sinus tract for x-ray", "code_information": [ { "code": "20501", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 381.92, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 693.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 693.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Inject trigger points 3/>", "code_information": [ { "code": "20553", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 217.58, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 778.72, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 1413.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 217.58, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 1413.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Inject/treat eye socket", "code_information": [ { "code": "67515", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 220.34, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 163.22, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 7462.32, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 13540.5, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 220.34, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 13540.5, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Injection ext venography", "code_information": [ { "code": "36005", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 16418.71, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 29792.04, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 29792.04, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Injection eye drug", "code_information": [ { "code": "67028", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 244.49, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 181.1, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 3383.34, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 6139.14, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 244.49, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 6139.14, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Injection for bladder x-ray", "code_information": [ { "code": "51600", "type": "HCPCS" }, { "code": "51610", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 1349.12, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 2448.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 2448.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Injection for cholangiogram", "code_information": [ { "code": "47531", "type": "HCPCS" }, { "code": "47532", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2601.27, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1926.87, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 3194.24, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 5796.01, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2601.27, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 5796.01, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Injection for hip x-ray", "code_information": [ { "code": "27093", "type": "HCPCS" }, { "code": "27095", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 4821.12, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 8748.02, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 8748.02, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Injection for myelogram", "code_information": [ { "code": "62284", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 6901.42, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 12522.74, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 12522.74, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Injection for shoulder x-ray", "code_information": [ { "code": "23350", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 3104.96, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 5634.01, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 5634.01, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Injection for spleen x-ray", "code_information": [ { "code": "38200", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 47258.24, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 85750.96, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 85750.96, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Injection for ureter x-ray", "code_information": [ { "code": "50690", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 456.32, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 828.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 828.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Injection for wrist x-ray", "code_information": [ { "code": "25246", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 4414.4, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 8010.02, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 8010.02, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Injection into hemorrhoid(s)", "code_information": [ { "code": "46500", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 672.02, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 2028.51, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 3680.77, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 672.02, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 3680.77, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Injection px for elbow arthg", "code_information": [ { "code": "24220", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 3710.08, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 6732.02, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 6732.02, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Injection treatment of eye", "code_information": [ { "code": "66020", "type": "HCPCS" }, { "code": "66030", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1681.13, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1245.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 6575.49, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 11931.33, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1681.13, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 11931.33, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Injection treatment of nerve", "code_information": [ { "code": "64600", "type": "HCPCS" }, { "code": "64605", "type": "HCPCS" }, { "code": "64610", "type": "HCPCS" }, { "code": "64630", "type": "HCPCS" }, { "code": "64640", "type": "HCPCS" }, { "code": "64680", "type": "HCPCS" }, { "code": "64681", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1439.39, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 486.1, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1066.21, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 3627.47, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 6582.11, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 656.23, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1439.39, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 6582.11, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "INOTUZUMAB OZOGAMICIN 0.9 MG IV SOLR", "drug_information": { "unit": "3.600000", "type": "UN" }, "code_information": [ { "code": "00008010001", "type": "NDC" } ], "standard_charges": [ { "minimum": 11394.0, "maximum": 63644.64, "gross_charge": 67707.06, "discounted_cash": 37238.88, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 39270.09, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 36968.05, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 54165.65, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 57347.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19702.75, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32499.39, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 40556.53, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 11394.0, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 63644.64, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 59582.21, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 19079.85, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 57551.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 50780.3, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 23853.2, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 46040.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 63644.64, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 53014.63, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 36968.05, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 15189.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 50780.3, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 59582.21, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 39270.09, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 36968.05, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Ins cath abd/l-ext art 1st", "code_information": [ { "code": "36245", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 36861.29, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 66885.44, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 66885.44, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Ins cath abd/l-ext art 2nd", "code_information": [ { "code": "36246", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 39120.55, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 70984.9, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 70984.9, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Ins cath abd/l-ext art 3rd", "code_information": [ { "code": "36247", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 40784.66, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 74004.45, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 74004.45, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Ins cath ren art 1st bilat", "code_information": [ { "code": "36252", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2320.02, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1718.54, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 17264.63, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 31326.95, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2320.02, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 31326.95, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Ins cath ren art 1st unilat", "code_information": [ { "code": "36251", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2320.02, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1718.54, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 18280.74, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 33170.71, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2320.02, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 33170.71, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Ins cath ren art 2nd+ bilat", "code_information": [ { "code": "36254", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2320.02, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1718.54, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 34874.71, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 63280.77, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2320.02, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 63280.77, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Ins cath ren art 2nd+ unilat", "code_information": [ { "code": "36253", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 3984.54, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2951.51, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 23128.49, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 41967.03, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3984.54, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 41967.03, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Ins endovas vena cava filtr", "code_information": [ { "code": "37191", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 3984.54, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2951.51, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 10811.38, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 19617.44, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3984.54, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 19617.44, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Ins mark abd/pel for rt perq", "code_information": [ { "code": "49411", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1008.54, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 747.07, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 25360.47, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 46017.01, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1008.54, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 46017.01, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Ins mark thor for rt perq", "code_information": [ { "code": "32553", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1008.54, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 747.07, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 17681.18, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 32082.8, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1008.54, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 32082.8, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Ins tun ip cath for dial opn", "code_information": [ { "code": "49421", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2601.27, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1926.87, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 6575.3, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 11931.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2601.27, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 11931.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Ins vag brachytx device", "code_information": [ { "code": "57156", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 224.22, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 166.09, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 7179.1, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 13026.6, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 224.22, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 13026.6, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Ins/rep subq defibrillator", "code_information": [ { "code": "33270", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 23632.59, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 17505.62, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 54588.83, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 99079.75, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23632.59, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 99079.75, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Ins/rpl prph sac/gstr npg/r", "code_information": [ { "code": "64590", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 15806.66, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 11708.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 35790.41, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 64942.29, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 15806.66, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 64942.29, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Ins/rplc spi npg/rcvr pocket", "code_information": [ { "code": "63685", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 22462.08, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 16638.58, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 59951.98, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 108783.83, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 22462.08, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 108783.83, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Insert 1 electrode pm-defib", "code_information": [ { "code": "33216", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 6100.22, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4518.69, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 19948.86, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 36197.54, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6100.22, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 36197.54, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Insert 2 electrode pm-defib", "code_information": [ { "code": "33217", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 6100.22, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4518.69, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 47310.52, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 85845.74, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6100.22, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 85845.74, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Insert abdomen-venous drain", "code_information": [ { "code": "49425", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 25351.62, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 46000.94, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 46000.94, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Insert ant drainage device", "code_information": [ { "code": "66183", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2965.25, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2196.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 7830.27, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 14208.17, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2965.25, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 14208.17, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Insert brain-fluid device", "code_information": [ { "code": "61215", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4720.44, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3496.62, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 18131.44, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 32921.42, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4720.44, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 32921.42, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Insert cath pleura w/ image", "code_information": [ { "code": "32557", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1145.04, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 848.18, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 14455.93, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 26230.53, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1145.04, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 26230.53, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Insert cath pleura w/o image", "code_information": [ { "code": "32556", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1398.27, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1035.76, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 23318.48, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 42311.82, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1398.27, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 42311.82, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Insert eye socket implant", "code_information": [ { "code": "67550", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2779.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2058.97, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 7459.84, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 13536.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2779.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 13536.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Insert heart pm atrial", "code_information": [ { "code": "33206", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 7713.99, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5714.07, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 54252.2, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 98441.52, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7713.99, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 98441.52, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Insert heart pm ventricular", "code_information": [ { "code": "33207", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 7713.99, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5714.07, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 22674.32, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 41142.95, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7713.99, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 41142.95, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Insert hepatic shunt (tips)", "code_information": [ { "code": "37182", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 33782.62, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 61299.1, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 61299.1, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Insert lens prosthesis", "code_information": [ { "code": "66985", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1681.13, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1245.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 11575.31, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 21003.58, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1681.13, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 21003.58, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Insert multi-comp penis pros", "code_information": [ { "code": "54405", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 14836.76, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 10990.19, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 37958.76, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 68876.76, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 14836.76, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 68876.76, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Insert ocular implant", "code_information": [ { "code": "65130", "type": "HCPCS" }, { "code": "65135", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2779.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2058.97, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 6595.31, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 11967.3, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2779.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 11967.3, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Insert pacing lead & connect", "code_information": [ { "code": "33224", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 7713.99, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5714.07, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 26438.99, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 47973.99, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7713.99, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 47973.99, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Insert pleural cath", "code_information": [ { "code": "32550", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2601.27, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1926.87, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 8400.42, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 15242.71, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2601.27, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 15242.71, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Insert pulse gen dual leads", "code_information": [ { "code": "33213", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 7713.99, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5714.07, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 23936.14, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 43432.53, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7713.99, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 43432.53, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Insert self-contd prosthesis", "code_information": [ { "code": "54401", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 14836.76, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 10990.19, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 40135.42, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 72833.62, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 14836.76, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 72833.62, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Insert semi-rigid prosthesis", "code_information": [ { "code": "54400", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 9576.71, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 7093.86, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 33908.86, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 61528.18, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 9576.71, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 61528.18, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Insert tissue expander(s)", "code_information": [ { "code": "11960", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2698.5, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1998.89, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 23910.05, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 43477.59, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2698.5, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 43477.59, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Insert tun ip cath perc", "code_information": [ { "code": "49418", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2601.27, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1926.87, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 13477.32, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 24454.83, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2601.27, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 24454.83, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Insert uro/ves nck sphincter", "code_information": [ { "code": "53445", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 14836.76, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 10990.19, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 42343.26, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 76832.52, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 14836.76, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 76832.52, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Insert uteri tandem/ovoids", "code_information": [ { "code": "57155", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 3638.66, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2695.3, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 26529.72, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 48138.6, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3638.66, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 48138.6, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Insertion drug dlvr implant", "code_information": [ { "code": "11981", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 95.01, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 70.38, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 3032.96, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 5503.36, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 95.01, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 5503.36, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Insertion of catheter vein", "code_information": [ { "code": "36481", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 24006.5, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 43560.19, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 43560.19, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Insertion of chest tube", "code_information": [ { "code": "32551", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1145.04, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 848.18, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 5646.24, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 10774.54, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1145.04, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 10774.54, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Insertion of iris prosthesis", "code_information": [ { "code": "0616T", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 22623.04, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 41049.87, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 41049.87, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Insj aqueous drain dev 1st", "code_information": [ { "code": "0449T", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 3803.22, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2817.2, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 9847.95, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 17869.25, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3803.22, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 17869.25, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Insj breast implt sm d mast", "code_information": [ { "code": "19340", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4806.97, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3560.72, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 29216.12, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 53013.14, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4806.97, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 53013.14, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Insj iris prosth sec io lens", "code_information": [ { "code": "0618T", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 35495.24, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 64406.7, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 64406.7, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Insj iris prosth w/rmvl&insj", "code_information": [ { "code": "0617T", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 25338.12, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 46280.93, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 46280.93, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Insj perq vad l hrt arterial", "code_information": [ { "code": "33990", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 83355.97, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 151250.89, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 151250.89, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Insj sinus tarsi implant", "code_information": [ { "code": "0335T", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 5265.64, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3900.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 8828.44, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 16019.33, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5265.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 16019.33, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Insj stablj dev w/dcmprn", "code_information": [ { "code": "22867", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 13555.31, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 10040.97, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 26587.75, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 48244.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 13555.31, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 48244.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Insj stablj dev w/o dcmprn", "code_information": [ { "code": "22869", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 9484.13, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 7025.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 23120.12, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 41951.84, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 9484.13, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 41951.84, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Insj subq car rhythm mntr", "code_information": [ { "code": "33285", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 6100.22, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4518.69, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 15729.82, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 28545.62, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6100.22, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 28545.62, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Insj/rplcmt brst implt sep d", "code_information": [ { "code": "19342", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 7053.35, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5224.7, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 15769.38, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 28613.8, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7053.35, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 28613.8, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Insj/rplcmt defib w/lead(s)", "code_information": [ { "code": "33249", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 23632.59, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 17505.62, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 54487.24, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 98867.98, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23632.59, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 98867.98, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Insrt heart pm atrial & vent", "code_information": [ { "code": "33208", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 7713.99, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5714.07, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 24160.5, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 43839.64, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7713.99, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 43839.64, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Insrt pulse gen w/dual leads", "code_information": [ { "code": "33230", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 16545.09, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 12255.62, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 88776.52, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 161086.52, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 16545.09, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 161086.52, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Insrt pulse gen w/mult leads", "code_information": [ { "code": "33231", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 23632.59, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 17505.62, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 45236.96, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 82083.2, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23632.59, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 82083.2, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Insrt/redo neurostim 1 array", "code_information": [ { "code": "61885", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 15806.66, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 11708.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 66660.02, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 121130.96, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 15806.66, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 121130.96, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Instill pharm renal pelvis", "code_information": [ { "code": "C9789", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1658.84, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1228.77, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 38834.32, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 70465.5, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1658.84, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 70465.5, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Instll rx agnt into rnal tub", "code_information": [ { "code": "50391", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 179.27, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 132.79, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 38834.32, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 70465.5, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 179.27, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 70465.5, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "INSULIN ASPART 10 UNITS/ML (DILUTED) IN NS (PEDS/NICU)", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "08252000112", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "INSULIN ASPART 100 UNIT/ML IJ SOLN", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "00169750111", "type": "NDC" } ], "standard_charges": [ { "minimum": 55.39, "maximum": 184.77, "gross_charge": 196.56, "discounted_cash": 108.11, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 114.0, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 107.32, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 157.25, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 166.49, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 57.2, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 94.35, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 117.74, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 117.54, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 184.77, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 172.97, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.39, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 167.08, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 147.42, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 69.25, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 133.66, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 184.77, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 153.91, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 107.32, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 156.27, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 147.42, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 172.97, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 114.0, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 107.32, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "INSULIN ASPART 100 UNIT/ML SC SOLN FOR PUMP", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "00169750111_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 55.39, "maximum": 184.77, "gross_charge": 196.56, "discounted_cash": 108.11, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 114.0, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 107.32, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 157.25, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 166.49, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 57.2, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 94.35, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 117.74, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 117.54, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 184.77, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 172.97, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.39, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 167.08, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 147.42, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 69.25, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 133.66, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 184.77, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 153.91, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 107.32, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 156.27, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 147.42, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 172.97, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 114.0, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 107.32, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "INSULIN ASPART 100 UNIT/ML SC SOPN", "drug_information": { "unit": "3.000000", "type": "UN" }, "code_information": [ { "code": "00169633910", "type": "NDC" } ], "standard_charges": [ { "minimum": 17.83, "maximum": 59.47, "gross_charge": 63.27, "discounted_cash": 34.8, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.7, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.55, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.62, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 53.59, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.41, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.37, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.9, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.84, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.47, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.68, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.83, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 53.78, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.45, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.29, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.02, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.47, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.54, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.55, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.3, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.45, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.68, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.7, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.55, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "INSULIN ASPART PROT & ASPART (70-30) 100 UNIT/ML SC SUSP", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "00169368512", "type": "NDC" } ], "standard_charges": [ { "minimum": 55.39, "maximum": 184.77, "gross_charge": 196.56, "discounted_cash": 108.11, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 114.0, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 107.32, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 157.25, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 166.49, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 57.2, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 94.35, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 117.74, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 117.54, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 184.77, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 172.97, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.39, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 167.08, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 147.42, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 69.25, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 133.66, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 184.77, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 153.91, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 107.32, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 156.27, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 147.42, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 172.97, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 114.0, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 107.32, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "INSULIN DEGLUDEC 100 UNIT/ML SC SOPN", "drug_information": { "unit": "3.000000", "type": "UN" }, "code_information": [ { "code": "00169266015", "type": "NDC" } ], "standard_charges": [ { "minimum": 77.86, "maximum": 259.71, "gross_charge": 276.29, "discounted_cash": 151.96, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 160.25, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 150.85, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 221.03, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 234.02, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 80.4, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 132.62, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 165.5, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 165.22, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 259.71, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 243.14, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 77.86, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 234.85, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 207.22, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 97.34, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 187.88, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 259.71, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 216.34, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 150.85, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 219.65, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 207.22, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 243.14, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 160.25, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 150.85, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "INSULIN DETEMIR 100 UNIT/ML SC SOLN", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "00169368712", "type": "NDC" } ], "standard_charges": [ { "minimum": 72.31, "maximum": 1158.0, "gross_charge": 256.59, "discounted_cash": 141.12, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 148.82, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 140.1, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 222.72, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.67, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 123.16, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 153.7, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 153.44, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 241.19, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 225.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 72.31, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 218.1, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 192.44, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 90.4, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 174.48, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 241.19, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 200.91, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 140.1, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 203.99, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 192.44, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 225.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 148.82, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 140.1, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "INSULIN GLARGINE 100 UNIT/ML SC SOLN", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "00088222033", "type": "NDC" } ], "standard_charges": [ { "minimum": 46.96, "maximum": 1158.0, "gross_charge": 166.65, "discounted_cash": 91.66, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.66, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 90.99, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 144.65, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 48.5, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 79.99, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 99.82, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 99.66, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 156.65, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 146.65, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.96, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 141.65, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 124.99, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 58.71, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 113.32, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 156.65, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 130.49, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 90.99, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 132.49, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 124.99, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 146.65, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.66, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 90.99, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "INSULIN GLARGINE 100 UNIT/ML SC SOPN", "drug_information": { "unit": "3.000000", "type": "UN" }, "code_information": [ { "code": "00088221905", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.74, "maximum": 39.17, "gross_charge": 41.67, "discounted_cash": 22.92, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.17, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.75, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.34, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.29, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.13, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.0, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.17, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.67, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.74, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.42, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.25, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.68, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.34, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.17, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.63, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.75, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.13, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.25, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.67, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.17, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.75, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "INSULIN GLULISINE 100 UNIT/ML IJ SOLN", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "00088250033", "type": "NDC" } ], "standard_charges": [ { "minimum": 64.58, "maximum": 1158.0, "gross_charge": 229.17, "discounted_cash": 126.04, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 132.92, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 125.13, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 198.92, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 66.69, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 110.0, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 137.27, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 137.04, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 215.42, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 201.67, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 64.58, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 194.79, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 171.88, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 80.74, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 155.84, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 215.42, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 179.44, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 125.13, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 182.19, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 171.88, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 201.67, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 132.92, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 125.13, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "INSULIN LISPRO (0.5 UNIT DIAL) 100 UNIT/ML SC SOPN", "drug_information": { "unit": "3.000000", "type": "UN" }, "code_information": [ { "code": "00002771459", "type": "NDC" } ], "standard_charges": [ { "minimum": 20.31, "maximum": 67.74, "gross_charge": 72.06, "discounted_cash": 39.63, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.79, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.34, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 57.65, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.03, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.97, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.59, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.16, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.09, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 67.74, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.41, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.31, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.25, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.05, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.39, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.0, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 67.74, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 56.42, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.34, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 57.29, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.05, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.41, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.79, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.34, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "INSULIN LISPRO 100 UNIT/ML IJ SOLN", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "00002773701", "type": "NDC" } ], "standard_charges": [ { "minimum": 15.96, "maximum": 53.23, "gross_charge": 56.63, "discounted_cash": 31.15, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.85, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.92, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.3, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.97, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.48, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.18, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.86, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 53.23, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.83, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.96, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 48.14, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.47, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.95, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.51, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 53.23, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 44.34, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.92, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.02, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.47, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.83, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.85, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.92, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "INSULIN LISPRO 100 UNIT/ML SC SOLN FOR PUMP", "drug_information": { "unit": "3.000000", "type": "UN" }, "code_information": [ { "code": "00002753301", "type": "NDC" } ], "standard_charges": [ { "minimum": 12.43, "maximum": 41.45, "gross_charge": 44.1, "discounted_cash": 24.26, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.58, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.08, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.28, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.35, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.83, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.17, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.42, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.37, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.45, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.81, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.43, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.49, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.08, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.54, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.99, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.45, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.53, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.08, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.06, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.08, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.81, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.58, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.08, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "INSULIN LISPRO PROT & LISPRO (50-50) 100 UNIT/ML SC SUSP", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "00002751201", "type": "NDC" } ], "standard_charges": [ { "minimum": 32.8, "maximum": 109.42, "gross_charge": 116.4, "discounted_cash": 64.02, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 67.51, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.55, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.12, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 98.59, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.87, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.87, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 69.72, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 69.61, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 109.42, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 102.43, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.8, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 98.94, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.3, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.01, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 79.15, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 109.42, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 91.14, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.55, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 92.54, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.3, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 102.43, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 67.51, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.55, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "INSULIN LISPRO PROT & LISPRO (75-25) 100 UNIT/ML SC SUPN", "drug_information": { "unit": "3.000000", "type": "UN" }, "code_information": [ { "code": "00002879759", "type": "NDC" } ], "standard_charges": [ { "minimum": 12.32, "maximum": 41.11, "gross_charge": 43.73, "discounted_cash": 24.05, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.36, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.88, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.98, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.04, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.73, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.99, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.19, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.15, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.11, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.48, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.32, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.8, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.74, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.11, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.24, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.88, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.77, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.8, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.48, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.36, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.88, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "INSULIN LISPRO PROT & LISPRO (75-25) 100 UNIT/ML SC SUSP", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "00002751101", "type": "NDC" } ], "standard_charges": [ { "minimum": 32.87, "maximum": 109.65, "gross_charge": 116.65, "discounted_cash": 64.16, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 67.66, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.69, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.32, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 98.8, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.95, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.99, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 69.87, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 69.76, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 109.65, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 102.65, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.87, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 99.15, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.49, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.1, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 79.32, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 109.65, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 91.34, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.69, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 92.74, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.49, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 102.65, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 67.66, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.69, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "INSULIN NPH (HUMAN) (ISOPHANE) 100 UNIT/ML SC SUSP", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "00002831501", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "INSULIN NPH ISOPHANE & REGULAR (70-30) 100 UNIT/ML SC SUPN", "drug_information": { "unit": "3.000000", "type": "UN" }, "code_information": [ { "code": "00002880359", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "INSULIN NPH ISOPHANE & REGULAR (70-30) 100 UNIT/ML SC SUSP", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "00002871501", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "INSULIN REGULAR HUMAN (CONC) 500 UNIT/ML SC SOLN", "drug_information": { "unit": "20.000000", "type": "UN" }, "code_information": [ { "code": "00002850101", "type": "NDC" } ], "standard_charges": [ { "minimum": 1127.18, "maximum": 3759.93, "gross_charge": 3999.93, "discounted_cash": 2199.96, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2319.96, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2183.96, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3199.94, 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Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2999.95, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1409.18, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2719.95, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3759.93, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3131.95, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2183.96, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3179.94, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2999.95, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3519.94, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2319.96, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2183.96, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "INSULIN REGULAR HUMAN (CONC) 500 UNIT/ML SC SOLN FOR PUMP", "drug_information": { "unit": "20.000000", "type": "UN" }, "code_information": [ { "code": "00002850101_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 1127.18, "maximum": 3759.93, "gross_charge": 3999.93, "discounted_cash": 2199.96, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2319.96, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2183.96, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3199.94, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3387.94, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1163.98, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1919.97, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2395.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2391.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3759.93, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3519.94, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1127.18, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3399.94, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2999.95, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1409.18, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2719.95, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3759.93, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3131.95, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2183.96, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3179.94, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2999.95, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3519.94, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2319.96, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2183.96, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "INSULIN REGULAR HUMAN 100 UNIT/ML 3 ML VIAL (BULK CHARGE)", "drug_information": { "unit": "3.000000", "type": "UN" }, "code_information": [ { "code": "00002021301", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "INSULIN REGULAR HUMAN 100 UNIT/ML FOR CORRECTIVE", "drug_information": { "unit": "3.000000", "type": "UN" }, "code_information": [ { "code": "00002021301_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total 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"methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "INSULIN REGULAR HUMAN 100 UNIT/ML FOR CORRECTIVE HIGH DOSE", "drug_information": { "unit": "3.000000", "type": "UN" }, "code_information": [ { "code": "00002021301_3", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All 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charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", 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"additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "INSULIN REGULAR HUMAN 100 UNIT/ML FOR NEU ORDERSETS", "drug_information": { "unit": "3.000000", "type": "UN" }, "code_information": [ { "code": "00002021301_4", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "INSULIN REGULAR HUMAN 100 UNIT/ML IJ SOLN", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "00002821501", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "INSULIN REGULAR HUMAN 100 UNIT/ML IVP ROUTE", "drug_information": { "unit": "3.000000", "type": "UN" }, "code_information": [ { "code": "00002021301_5", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "INSULIN REGULAR HUMAN 100 UNITS/100 ML (PEDS DKA) DRIP >/= 11 YO RTU", "drug_information": { "unit": "100.000000", "type": "UN" }, "code_information": [ { "code": "00338012612", "type": "NDC" } ], "standard_charges": [ { "minimum": 12.76, "maximum": 1158.0, "gross_charge": 45.29, "discounted_cash": 24.91, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.27, "standard_charge_percentage": 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"additional_payer_notes": "N/A", "standard_charge_dollar": 12.76, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.97, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.96, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.8, "standard_charge_percentage": 68.0, "methodology": "percent of 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"standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.86, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.27, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.73, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "INSULIN REGULAR HUMAN 100 UNITS/100 ML (PEDS DKA) DRIP 6-10 YO RTU", "drug_information": { "unit": "100.000000", "type": "UN" }, "code_information": [ { "code": "00338012612_2", "type": "NDC" } ], "standard_charges": [ { 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charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.86, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.76, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.97, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", 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], "additional_generic_notes": "" } ] }, { "description": "INSULIN REGULAR HUMAN 100 UNITS/100 ML DRIP (DKA) RTU", "drug_information": { "unit": "100.000000", "type": "UN" }, "code_information": [ { "code": "00338012612_3", "type": "NDC" } ], "standard_charges": [ { "minimum": 12.76, "maximum": 1158.0, "gross_charge": 45.29, "discounted_cash": 24.91, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.27, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.73, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.31, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.18, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.74, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.13, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.08, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.57, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.86, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.76, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.97, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.96, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.57, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.46, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.73, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.01, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.97, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.86, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.27, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.73, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "INSULIN REGULAR HUMAN 100 UNITS/100 ML DRIP (NSURG) RTU", "drug_information": { "unit": "100.000000", "type": "UN" }, "code_information": [ { "code": "00338012612_4", "type": "NDC" } ], "standard_charges": [ { "minimum": 12.76, "maximum": 1158.0, "gross_charge": 45.29, "discounted_cash": 24.91, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.27, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.73, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.31, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.18, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.74, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.13, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.08, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.57, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.86, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.76, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.97, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.96, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", 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"additional_payer_notes": "N/A", "standard_charge_dollar": 39.86, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.27, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.73, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "INSULIN REGULAR HUMAN 100 UNITS/100 ML DRIP (PEDS) RTU", "drug_information": { "unit": "100.000000", "type": "UN" }, "code_information": [ { "code": "00338012612_5", "type": "NDC" } ], "standard_charges": [ { "minimum": 12.76, "maximum": 1158.0, "gross_charge": 45.29, "discounted_cash": 24.91, "setting": "inpatient", "payers_information": [ { "payer_name": 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"standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.76, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.97, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.96, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": 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"drug_information": { "unit": "100.000000", "type": "UN" }, "code_information": [ { "code": "00338012612_6", "type": "NDC" } ], "standard_charges": [ { "minimum": 12.76, "maximum": 1158.0, "gross_charge": 45.29, "discounted_cash": 24.91, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.27, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.73, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.31, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.18, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.74, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.13, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.08, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.57, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.86, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.76, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.97, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.96, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.57, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.46, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", 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"Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.73, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "INSULIN REGULAR HUMAN 100 UNITS/100 ML DRIP FOR ICU DRIP RTU", "drug_information": { "unit": "100.000000", "type": "UN" }, "code_information": [ { "code": "00338012612_7", "type": "NDC" } ], "standard_charges": [ { "minimum": 12.76, "maximum": 1158.0, "gross_charge": 45.29, "discounted_cash": 24.91, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.27, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.73, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.31, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.18, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.74, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.13, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.08, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.57, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.86, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.76, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.97, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.96, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.57, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.46, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.73, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.01, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.97, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.86, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.27, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.73, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "INSULIN REGULAR HUMAN 100 UNITS/100 ML DRIP FOR TYPE 1 DM RTU", "drug_information": { "unit": "100.000000", "type": "UN" }, "code_information": [ { "code": "00338012612_8", "type": "NDC" } ], "standard_charges": [ { "minimum": 12.76, "maximum": 1158.0, "gross_charge": 45.29, "discounted_cash": 24.91, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.27, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.73, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.31, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.18, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.74, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.13, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.08, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.57, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.86, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.76, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.97, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.96, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.57, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.46, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.73, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.01, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.97, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.86, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.27, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.73, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "INSULIN REGULAR HUMAN 100 UNITS/100 ML DRIP RTU", "drug_information": { "unit": "100.000000", "type": "UN" }, "code_information": [ { "code": "00338012612_9", "type": "NDC" } ], "standard_charges": [ { "minimum": 12.76, "maximum": 1158.0, "gross_charge": 45.29, "discounted_cash": 24.91, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.27, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.73, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.31, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.18, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.74, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.13, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.08, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.57, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.86, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.76, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.97, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 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"additional_payer_notes": "N/A", "standard_charge_dollar": 36.01, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.97, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.86, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.27, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.73, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Int hrhc lig 1 hroid w/o img", "code_information": [ { "code": "46945", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2021.42, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1497.34, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 6665.74, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 12095.1, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2021.42, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 12095.1, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Int hrhc lig 2+hroid w/o img", "code_information": [ { "code": "46946", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2021.42, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1497.34, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 6708.53, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 12172.73, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2021.42, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 12172.73, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Interdental fixation", "code_information": [ { "code": "21110", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1091.85, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 808.78, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 44402.79, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 80569.58, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1091.85, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 80569.58, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Interdiscal perq aspir dx", "code_information": [ { "code": "62267", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 518.62, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 384.16, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 3326.67, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 6237.9, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 518.62, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 6237.9, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "INTERFERON BETA-1A 22 MCG/0.5ML SC SOSY", "drug_information": { "unit": "0.500000", "type": "UN" }, "code_information": [ { "code": "44087002203", "type": "NDC" } ], "standard_charges": [ { "minimum": 962.7, "maximum": 3211.27, "gross_charge": 3416.24, "discounted_cash": 1878.93, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1981.42, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1865.27, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2732.99, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2893.56, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 994.13, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1639.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2046.33, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2042.91, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3211.27, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3006.29, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 962.7, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2903.8, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2562.18, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1203.54, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2323.04, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3211.27, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2674.92, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1865.27, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2715.91, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2562.18, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3006.29, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1981.42, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1865.27, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "INTERFERON BETA-1A 30 MCG/0.5ML IM AJKT", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "59627033304", "type": "NDC" } ], "standard_charges": [ { "minimum": 30.7, "maximum": 21111.59, "gross_charge": 22459.14, "discounted_cash": 12352.53, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 13026.3, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.7, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17967.31, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19022.89, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6535.61, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10780.39, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 13453.02, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 11394.0, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21111.59, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19764.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 6328.99, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19090.27, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16844.36, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 7912.36, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 15272.22, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 21111.59, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 17585.51, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.45, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 15189.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16844.36, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19764.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 13026.3, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.7, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "INTERFERON BETA-1A 30 MCG/0.5ML IM PSKT", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "59627022205", "type": "NDC" } ], "standard_charges": [ { "minimum": 30.7, "maximum": 5277.9, "gross_charge": 5614.79, "discounted_cash": 3088.13, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3256.58, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.7, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4491.83, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4755.73, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1633.9, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2695.1, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3363.26, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 3357.64, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5277.9, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4941.02, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1582.25, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4772.57, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4211.09, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1978.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3818.06, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5277.9, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4396.38, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.45, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4463.76, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4211.09, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4941.02, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3256.58, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.7, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "INTERFERON BETA-1A 44 MCG/0.5ML SC SOSY", "drug_information": { "unit": "0.500000", "type": "UN" }, "code_information": [ { "code": "44087004403", "type": "NDC" } ], "standard_charges": [ { "minimum": 898.88, "maximum": 2998.39, "gross_charge": 3189.78, "discounted_cash": 1754.38, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1850.07, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1741.62, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2551.82, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2701.74, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 928.23, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1531.09, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1910.68, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 1907.49, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2998.39, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2807.01, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 898.88, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2711.31, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2392.34, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1123.76, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2169.05, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2998.39, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2497.6, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1741.62, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2535.88, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2392.34, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2807.01, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1850.07, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1741.62, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "INTERFERON BETA-1A 6X8.8 & 6X22 MCG SC SOSY", "drug_information": { "unit": "4.200000", "type": "UN" }, "code_information": [ { "code": "44087882201", "type": "NDC" } ], "standard_charges": [ { "minimum": 8089.93, "maximum": 26985.57, "gross_charge": 28708.05, "discounted_cash": 15789.43, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 16650.67, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 15674.6, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 22966.44, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 24315.72, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8354.04, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13779.86, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 17196.12, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 11394.0, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 26985.57, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 25263.08, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 8089.93, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 24401.84, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21531.04, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 10113.85, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 19521.47, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 26985.57, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 22478.4, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 15674.6, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 15189.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21531.04, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 25263.08, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 16650.67, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 15674.6, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "INTERFERON BETA-1B 0.3 MG SC KIT", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "50419052435", "type": "NDC" } ], "standard_charges": [ { "minimum": 761.68, "maximum": 2540.74, "gross_charge": 2702.92, "discounted_cash": 1486.61, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1567.69, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1475.79, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2162.34, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2289.37, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 786.55, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1297.4, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1619.05, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 1616.35, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2540.74, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2378.57, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 761.68, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2297.48, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2027.19, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 952.24, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1837.99, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2540.74, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2116.39, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1475.79, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2148.82, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2027.19, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2378.57, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1567.69, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1475.79, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "INTERFERON GAMMA-1B 100 MCG/0.5ML SC SOLN", "drug_information": { "unit": "0.500000", "type": "UN" }, "code_information": [ { "code": "75987011110", "type": "NDC" } ], "standard_charges": [ { "minimum": 1561.64, "maximum": 5209.16, "gross_charge": 5541.66, "discounted_cash": 3047.91, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3214.16, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3025.75, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4433.33, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4693.79, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1612.62, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2660.0, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3319.45, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 3313.91, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5209.16, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4876.66, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1561.64, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4710.41, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4156.25, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1952.33, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3768.33, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5209.16, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4339.12, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3025.75, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4405.62, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4156.25, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4876.66, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3214.16, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3025.75, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Intestinal stricturoplasty", "code_information": [ { "code": "44615", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 32099.94, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 58245.86, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 58245.86, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Intmd rpr face/mm 12.6-20 cm", "code_information": [ { "code": "12055", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 294.49, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 218.14, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 7638.39, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 13870.8, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 294.49, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 13870.8, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Intmd rpr face/mm 2.5 cm/<", "code_information": [ { "code": "12051", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 294.49, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 2484.96, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 4509.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 294.49, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 4509.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Intmd rpr face/mm 2.6-5.0 cm", "code_information": [ { "code": "12052", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 294.49, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 1889.76, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 3429.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 294.49, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 3429.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Intmd rpr face/mm 5.1-7.5 cm", "code_information": [ { "code": "12053", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 294.49, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 1800.48, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 3267.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 294.49, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 3267.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Intmd rpr face/mm 7.6-12.5cm", "code_information": [ { "code": "12054", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 294.49, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 218.14, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 5922.24, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 10746.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 294.49, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 10746.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Intmd rpr n-hf/genit 2.5cm/<", "code_information": [ { "code": "12041", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 294.49, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 218.14, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 3769.6, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 6840.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 294.49, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 6840.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Intmd rpr n-hf/genit2.6-7.5", "code_information": [ { "code": "12042", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 294.49, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 2795.56, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 5072.58, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 294.49, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 5072.58, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Intmd rpr s/a/t/ext 12.6-20", "code_information": [ { "code": "12035", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 294.49, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 218.14, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 11137.7, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 20217.3, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 294.49, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 20217.3, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Intmd rpr s/a/t/ext 2.5 cm/<", "code_information": [ { "code": "12031", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 294.49, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 218.14, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 2410.56, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 4374.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 294.49, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 4374.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Intmd rpr s/a/t/ext 2.6-7.5", "code_information": [ { "code": "12032", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 294.49, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 2108.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 3825.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 294.49, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 3825.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Intmd rpr s/a/t/ext 20.1-30", "code_information": [ { "code": "12036", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 451.2, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 334.22, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 12700.08, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 23057.3, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 451.2, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 23057.3, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Intmd rpr s/tr/ext >30.0 cm", "code_information": [ { "code": "12037", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1348.33, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 998.76, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 11212.62, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 20345.48, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1348.33, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 20345.48, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Intmd rpr s/tr/ext 7.6-12.5", "code_information": [ { "code": "12034", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 294.49, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 218.14, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 6564.56, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 11911.5, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 294.49, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 11911.5, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Intranasal biopsy", "code_information": [ { "code": "30100", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1091.85, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 808.78, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 10769.41, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 19541.28, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1091.85, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 19541.28, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Intro cath dialysis circuit", "code_information": [ { "code": "36901", "type": "HCPCS" }, { "code": "36902", "type": "HCPCS" }, { "code": "36903", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 8359.13, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 848.18, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3113.03, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 6191.95, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 12356.24, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 22420.61, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1145.04, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4202.59, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8359.13, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 22420.61, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Intro ndl icath upr/lxtr art", "code_information": [ { "code": "36140", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 27824.45, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 50487.88, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 50487.88, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "IOBENGUANE SULFATE I 123 10 MCI/5ML IV SOLN", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "17156023501", "type": "NDC" } ], "standard_charges": [ { "minimum": 1132.85, "maximum": 11069.21, "gross_charge": 11775.75, "discounted_cash": 6476.66, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 6829.94, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1132.85, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9420.6, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9974.06, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3426.74, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5652.36, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7053.67, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 7041.9, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11069.21, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10362.66, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3318.41, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10009.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8831.81, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 4148.6, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 8007.51, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 11069.21, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 9220.41, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1529.34, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 9361.72, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8831.81, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10362.66, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6829.94, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1132.85, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "IODINE STRONG 5 % PO SOLN", "drug_information": { "unit": "0.100000", "type": "UN" }, "code_information": [ { "code": "48433023015", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "IODINE STRONG 5 % PO SOLN (MULTI-GPI)", "drug_information": { "unit": "0.100000", "type": "UN" }, "code_information": [ { "code": "48433023015_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "IOFLUPANE I 123 185 MBQ/2.5ML IV SOLN", "drug_information": { "unit": "2.500000", "type": "UN" }, "code_information": [ { "code": "17156021001", "type": "NDC" } ], "standard_charges": [ { "minimum": 1944.42, "maximum": 6486.0, "gross_charge": 6900.0, "discounted_cash": 3795.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4002.0, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3767.4, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5520.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": 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charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6486.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6072.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1944.42, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5865.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5175.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2430.87, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4692.0, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6486.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5402.7, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3767.4, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5485.5, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5175.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6072.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4002.0, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3767.4, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "IOPANOIC ACID 500MG CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "P5192735800", "type": "NDC" } ], "standard_charges": [ { "minimum": 7.04, "maximum": 1158.0, "gross_charge": 24.99, "discounted_cash": 13.74, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.49, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.64, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.69, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.27, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.0, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.97, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.94, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.49, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.99, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.24, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.74, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.8, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.99, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.49, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.57, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.64, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.87, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.74, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.99, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.49, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.64, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "IPILIMUMAB 200 MG/40ML IV SOLN", "drug_information": { "unit": "40.000000", "type": "UN" }, "code_information": [ { "code": "00003232822", "type": "NDC" } ], "standard_charges": [ { "minimum": 96.58, "maximum": 76241.01, "gross_charge": 81107.46, "discounted_cash": 44609.1, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 47042.33, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.58, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 64885.97, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 68698.02, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23602.27, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38931.58, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 48583.37, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 11394.0, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 76241.01, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 71374.56, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 22856.08, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 68941.34, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 60830.6, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 28574.16, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 55153.07, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 76241.01, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63507.14, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 130.38, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 15189.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 60830.6, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 71374.56, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 47042.33, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.58, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "IPILIMUMAB 50 MG/10ML IV SOLN", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "00003232711", "type": "NDC" } ], "standard_charges": [ { "minimum": 7357.63, "maximum": 24542.85, "gross_charge": 26109.42, "discounted_cash": 14360.18, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 15143.46, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 14255.74, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20887.54, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 22114.68, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7597.84, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12532.52, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 15639.54, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 11394.0, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 24542.85, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 22976.29, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 7357.63, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 22193.01, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19582.07, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 9198.35, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 17754.41, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 24542.85, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 20443.68, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 14255.74, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 15189.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19582.07, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 22976.29, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 15143.46, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 14255.74, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "IPRATROPIUM BROMIDE 0.02 % IN SOLN", "drug_information": { "unit": "2.500000", "type": "UN" }, "code_information": [ { "code": "76204010001", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "IPRATROPIUM BROMIDE 0.03 % NA SOLN", "drug_information": { "unit": "30.000000", "type": "UN" }, "code_information": [ { "code": "00054004544", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.66, "maximum": 38.9, "gross_charge": 41.38, "discounted_cash": 22.76, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.0, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.59, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.1, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.05, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.04, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.86, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.79, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.75, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.9, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.41, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.66, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.04, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.58, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.14, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.9, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.4, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.59, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.9, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.04, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.41, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.0, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.59, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "IPRATROPIUM BROMIDE 0.06 % NA SOLN", "drug_information": { "unit": "15.000000", "type": "UN" }, "code_information": [ { "code": "00054004641", "type": "NDC" } ], "standard_charges": [ { "minimum": 5.62, "maximum": 18.75, "gross_charge": 19.95, "discounted_cash": 10.97, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.57, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.89, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.96, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.9, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.81, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.58, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.95, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.93, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.75, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.56, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.62, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.96, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.96, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.03, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.57, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.75, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.62, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.89, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.86, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.96, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.56, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.57, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.89, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "IPRATROPIUM BROMIDE HFA 17 MCG/ACT IN AERS", "drug_information": { "unit": "13.000000", "type": "GR" }, "code_information": [ { "code": "00597008717", "type": "NDC" } ], "standard_charges": [ { "minimum": 602.42, "maximum": 2009.49, "gross_charge": 2137.75, "discounted_cash": 1175.76, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1239.9, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1167.21, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1710.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1810.67, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 622.09, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1026.12, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1280.51, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 1278.37, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2009.49, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1881.22, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 602.42, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1817.09, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1603.31, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 753.13, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1453.67, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2009.49, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1673.86, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1167.21, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1699.51, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1603.31, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1881.22, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1239.9, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1167.21, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN", "drug_information": { "unit": "3.000000", "type": "UN" }, "code_information": [ { "code": "60687040583", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "IPRATROPIUM-ALBUTEROL 20-100 MCG/ACT IN AERS", "drug_information": { "unit": "4.000000", "type": "GR" }, "code_information": [ { "code": "00597002402", "type": "NDC" } ], "standard_charges": [ { "minimum": 310.98, "maximum": 1037.34, "gross_charge": 1103.55, "discounted_cash": 606.95, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 640.06, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 602.54, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 882.84, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 934.71, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 321.13, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 529.7, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 661.03, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 659.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1037.34, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 971.12, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 310.98, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 938.02, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 827.66, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 388.78, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 750.41, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1037.34, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 864.08, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 602.54, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 877.32, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 827.66, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 971.12, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 640.06, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 602.54, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "IRBESARTAN 150 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "33342004807", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "IRBESARTAN 300 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00955104290", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Ire abltj 1+tum organ perq", "code_information": [ { "code": "0600T", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 7674.11, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5684.53, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 36077.93, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 65463.98, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7674.11, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 65463.98, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Ire abltj 1+tumors open", "code_information": [ { "code": "0601T", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 7674.11, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5684.53, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 49722.41, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 90222.16, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7674.11, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 90222.16, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "IRINOTECAN HCL 100 MG/5ML IV SOLN", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "60505612801", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "IRINOTECAN HCL 40 MG/2ML IV SOLN", "drug_information": { "unit": "2.000000", "type": "UN" }, "code_information": [ { "code": "60505612800", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "IRINOTECAN HCL LIPOSOME 43 MG/10ML IV INJ", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "15054004301", "type": "NDC" } ], "standard_charges": [ { "minimum": 35.36, "maximum": 8194.92, "gross_charge": 8718.0, "discounted_cash": 4794.9, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5056.44, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.36, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6974.4, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7384.15, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2536.94, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4184.64, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5222.08, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 5213.36, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8194.92, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7671.84, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2456.73, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7410.3, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6538.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3071.35, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5928.24, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 8194.92, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6826.19, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.74, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6930.81, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6538.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7671.84, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5056.44, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.36, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "IRINOTECAN IN LC BEADS 100-300 MICRON", "drug_information": { "unit": "100.000000", "type": "ME" }, "code_information": [ { "code": "00009752903", "type": "NDC" } ], "standard_charges": [ { "minimum": 32.78, "maximum": 109.35, "gross_charge": 116.33, "discounted_cash": 63.98, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 67.47, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.52, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.06, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 98.53, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.85, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.84, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 69.68, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 69.57, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 109.35, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 102.37, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.78, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 98.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.25, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.98, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 79.1, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 109.35, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 91.09, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.52, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 92.48, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.25, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 102.37, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 67.47, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.52, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "IRINOTECAN IN LC BEADS 70-150 MICRON", "drug_information": { "unit": "100.000000", "type": "ME" }, "code_information": [ { "code": "00009752903_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 32.78, "maximum": 109.35, "gross_charge": 116.33, "discounted_cash": 63.98, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 67.47, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.52, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.06, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 98.53, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.85, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.84, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 69.68, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 69.57, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 109.35, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 102.37, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.78, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 98.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.25, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.98, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 79.1, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 109.35, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 91.09, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.52, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 92.48, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.25, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 102.37, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 67.47, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.52, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "IRINOTECAN IN ONCOZENE MICROSPHERES 100 MICRON", "drug_information": { "unit": "100.000000", "type": "ME" }, "code_information": [ { "code": "00009752903_3", "type": "NDC" } ], "standard_charges": [ { "minimum": 32.78, "maximum": 109.35, "gross_charge": 116.33, "discounted_cash": 63.98, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 67.47, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.52, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.06, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 98.53, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.85, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.84, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 69.68, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 69.57, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 109.35, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 102.37, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.78, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 98.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.25, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.98, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 79.1, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 109.35, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 91.09, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.52, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 92.48, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.25, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 102.37, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 67.47, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.52, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "IRINOTECAN IN ONCOZENE MICROSPHERES 40 MICRON", "drug_information": { "unit": "100.000000", "type": "ME" }, "code_information": [ { "code": "00009752903_4", "type": "NDC" } ], "standard_charges": [ { "minimum": 32.78, "maximum": 109.35, "gross_charge": 116.33, "discounted_cash": 63.98, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 67.47, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.52, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.06, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 98.53, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.85, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.84, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 69.68, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 69.57, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 109.35, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 102.37, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.78, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 98.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.25, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.98, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 79.1, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 109.35, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 91.09, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.52, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 92.48, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.25, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 102.37, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 67.47, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.52, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "IRINOTECAN IN ONCOZENE MICROSPHERES 75 MICRON", "drug_information": { "unit": "100.000000", "type": "ME" }, "code_information": [ { "code": "00009752903_5", "type": "NDC" } ], "standard_charges": [ { "minimum": 32.78, "maximum": 109.35, "gross_charge": 116.33, "discounted_cash": 63.98, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 67.47, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.52, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.06, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 98.53, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.85, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.84, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 69.68, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 69.57, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 109.35, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 102.37, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.78, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 98.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.25, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.98, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 79.1, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 109.35, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 91.09, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.52, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 92.48, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.25, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 102.37, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 67.47, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.52, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "IRON DEXTRAN 50 MG/ML IJ SOLN", "drug_information": { "unit": "0.500000", "type": "UN" }, "code_information": [ { "code": "00023608210", "type": "NDC" } ], "standard_charges": [ { "minimum": 9.65, "maximum": 75.54, "gross_charge": 80.36, "discounted_cash": 44.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.61, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.65, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 64.29, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 68.06, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.38, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.57, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 48.14, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 48.06, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.54, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 70.72, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.65, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 68.31, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.27, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.31, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.64, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.54, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 62.92, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.02, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.89, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.27, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 70.72, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.61, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.65, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "IRON DEXTRAN SYRINGE (<100 MG)", "drug_information": { "unit": "2.000000", "type": "UN" }, "code_information": [ { "code": "00023608210_4", "type": "NDC" } ], "standard_charges": [ { "minimum": 9.65, "maximum": 141.34, "gross_charge": 150.36, "discounted_cash": 82.7, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.21, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.65, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 120.29, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 127.35, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.75, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 72.17, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 90.07, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 89.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 141.34, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 132.32, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.37, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 127.81, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 112.77, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.97, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 102.24, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 141.34, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 117.73, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.02, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 119.54, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 112.77, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 132.32, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.21, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.65, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "IRON DEXTRAN SYRINGE (<100 MG)|DISCARDED DRUG NOT ADMINISTERED", "drug_information": { "unit": "2.000000", "type": "UN" }, "code_information": [ { "code": "00023608210_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 9.65, "maximum": 75.54, "gross_charge": 80.36, "discounted_cash": 44.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.61, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.65, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 64.29, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 68.06, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.38, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.57, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 48.14, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 48.06, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.54, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 70.72, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.65, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 68.31, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.27, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.31, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.64, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.54, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 62.92, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.02, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.89, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.27, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 70.72, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.61, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.65, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "IRON DEXTRAN SYRINGE (TEST DOSE)", "drug_information": { "unit": "2.000000", "type": "UN" }, "code_information": [ { "code": "00023608210_5", "type": "NDC" } ], "standard_charges": [ { "minimum": 9.65, "maximum": 141.34, "gross_charge": 150.36, "discounted_cash": 82.7, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.21, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.65, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 120.29, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 127.35, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.75, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 72.17, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 90.07, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 89.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 141.34, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 132.32, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.37, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 127.81, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 112.77, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.97, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 102.24, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 141.34, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 117.73, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.02, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 119.54, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 112.77, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 132.32, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.21, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.65, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "IRON DEXTRAN SYRINGE (TEST DOSE)|DISCARDED DRUG NOT ADMINISTERED", "drug_information": { "unit": "2.000000", "type": "UN" }, "code_information": [ { "code": "00023608210_3", "type": "NDC" } ], "standard_charges": [ { "minimum": 9.65, "maximum": 75.54, "gross_charge": 80.36, "discounted_cash": 44.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.61, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.65, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 64.29, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 68.06, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.38, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.57, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 48.14, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 48.06, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.54, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 70.72, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.65, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 68.31, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.27, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.31, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.64, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.54, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 62.92, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.02, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.89, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.27, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 70.72, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.61, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.65, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "IRON SUCROSE 20 MG/ML IV SOLN", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "00517234010", "type": "NDC" } ], "standard_charges": [ { "minimum": 22.65, "maximum": 75.57, "gross_charge": 80.39, "discounted_cash": 44.21, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.63, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.89, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 64.31, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 68.09, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.39, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.59, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 48.15, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 48.07, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.57, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 70.74, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.65, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 68.33, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.29, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.32, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.67, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.57, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 62.95, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.89, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.91, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.29, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 70.74, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.63, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.89, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Irrigation maxillary sinus", "code_information": [ { "code": "31000", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 171.17, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 126.79, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 11750.24, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 21320.99, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 171.17, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 21320.99, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Irrigation sphenoid sinus", "code_information": [ { "code": "31002", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1091.85, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 808.78, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 11750.24, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 21320.99, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1091.85, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 21320.99, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ISATUXIMAB-IRFC 100 MG/5ML IV SOLN", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "00024065401", "type": "NDC" } ], "standard_charges": [ { "minimum": 42.62, "maximum": 2976.0, "gross_charge": 3165.96, "discounted_cash": 1741.28, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1836.26, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.62, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2532.77, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2681.57, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 921.29, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1519.66, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1896.41, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 1893.24, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2976.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2786.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 892.17, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2691.07, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2374.47, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1115.37, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2152.85, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2976.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2478.95, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 57.53, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2516.94, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2374.47, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2786.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1836.26, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.62, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "ISATUXIMAB-IRFC 500 MG/25ML IV SOLN", "drug_information": { "unit": "25.000000", "type": "UN" }, "code_information": [ { "code": "00024065601", "type": "NDC" } ], "standard_charges": [ { "minimum": 42.62, "maximum": 11160.09, "gross_charge": 11872.44, "discounted_cash": 6529.84, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 6886.02, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.62, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9497.95, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10055.96, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3454.88, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5698.77, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7111.59, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 7099.72, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11160.09, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10447.75, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3345.65, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10091.57, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8904.33, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 4182.66, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 8073.26, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 11160.09, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 9296.12, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 57.53, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 9438.59, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8904.33, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10447.75, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6886.02, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.62, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "ISAVUCONAZONIUM SULFATE 186 MG PO CAPS", "drug_information": { "unit": "2.000000", "type": "UN" }, "code_information": [ { "code": "00469052002", "type": "NDC" } ], "standard_charges": [ { "minimum": 137.67, "maximum": 459.23, "gross_charge": 488.54, "discounted_cash": 268.7, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 283.35, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 266.74, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 390.83, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 413.79, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 142.17, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 234.5, "standard_charge_percentage": 48.0, "methodology": "percent of total 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"standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 415.26, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 366.41, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 172.11, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 332.21, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", 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charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 429.92, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 283.35, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 266.74, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ISAVUCONAZONIUM SULFATE 372 MG IV SOLR", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "00469042001", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.54, "maximum": 1043.14, "gross_charge": 1109.72, "discounted_cash": 610.35, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 643.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.54, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 887.78, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 939.93, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 322.93, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 532.67, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 664.72, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 663.61, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1043.14, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 976.55, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 312.72, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 943.26, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 832.29, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 390.95, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 754.61, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1043.14, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 868.91, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.72, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 882.23, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 832.29, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 976.55, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 643.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.54, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "ISAVUCONAZONIUM SULFATE 74.5 MG PO CAPS", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "00469286035", "type": "NDC" } ], "standard_charges": [ { "minimum": 114.97, "maximum": 383.5, "gross_charge": 407.98, "discounted_cash": 224.39, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 236.63, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 222.76, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 326.38, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 345.56, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 118.72, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 195.83, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 244.38, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 243.97, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 383.5, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 359.02, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 114.97, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 346.78, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 305.99, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 143.73, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 277.43, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 383.5, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 319.45, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 222.76, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 324.34, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 305.99, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 359.02, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 236.63, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 222.76, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Island pedicle flap graft", "code_information": [ { "code": "15740", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1348.33, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 998.76, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 14639.46, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 26563.54, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1348.33, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 26563.54, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ISOFLURANE IN SOLN", "drug_information": { "unit": "100.000000", "type": "UN" }, "code_information": [ { "code": "10019036040", "type": "NDC" } ], "standard_charges": [ { "minimum": 14.74, "maximum": 1158.0, "gross_charge": 52.31, "discounted_cash": 28.77, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.34, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.56, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.41, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.22, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.11, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.33, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.28, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.17, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.03, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.74, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 44.46, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.23, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.43, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.57, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.17, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.96, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.56, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.59, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.23, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.03, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.34, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.56, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ISOLEUCINE 10 MG/ML SOLUTION", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "P5155241205", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 1158.0, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.47, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ISOLEUCINE 20 MG/ML SOLUTION", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "P5155241210", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 1158.0, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.47, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ISOLYTE-S PH 7.4 IV BOLUS", "drug_information": { "unit": "1000.000000", "type": "UN" }, "code_information": [ { "code": "00264770700", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 1158.0, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.72, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ISOLYTE-S PH 7.4 IV SOLN", "drug_information": { "unit": "1000.000000", "type": "UN" }, "code_information": [ { "code": "00264770700_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 19.73, "maximum": 1158.0, "gross_charge": 70.0, "discounted_cash": 38.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.76, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.37, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.93, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.86, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.73, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.66, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.6, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.81, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.65, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ISONIAZID 100 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00555006602", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ISONIAZID 300 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "51079008320", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ISONIAZID 50 MG/5ML PO SYRP", "drug_information": { "unit": "473.000000", "type": "UN" }, "code_information": [ { "code": "46287000901", "type": "NDC" } ], "standard_charges": [ { "minimum": 186.32, "maximum": 621.51, "gross_charge": 661.18, "discounted_cash": 363.65, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 383.48, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 361.0, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 528.94, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 560.02, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 192.4, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 317.37, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 396.05, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 395.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 621.51, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 581.84, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 186.32, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 562.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 495.89, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 232.93, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 449.6, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 621.51, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 517.7, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 361.0, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 525.64, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 495.89, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 581.84, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 383.48, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 361.0, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ISOPROPYL ALCOHOL (RUBBING) 70 % SOLN", "drug_information": { "unit": "3840.000000", "type": "UN" }, "code_information": [ { "code": "00395124928", "type": "NDC" } ], "standard_charges": [ { "minimum": 22.09, "maximum": 73.68, "gross_charge": 78.38, "discounted_cash": 43.11, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.46, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.8, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 62.7, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 66.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.81, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.62, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.95, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.87, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 73.68, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 68.97, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.09, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 66.62, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 58.79, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.61, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 53.3, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 73.68, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.37, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.8, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 62.31, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 58.79, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 68.97, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.46, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.8, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ISOPROTERENOL HCL 0.2 MG/ML IJ SOLN", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "00548950200", "type": "NDC" } ], "standard_charges": [ { "minimum": 178.66, "maximum": 1158.0, "gross_charge": 633.99, "discounted_cash": 348.69, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 367.71, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 346.16, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 550.3, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 184.49, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 304.32, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 379.76, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 379.13, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 595.95, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 557.91, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 178.66, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 538.89, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 475.49, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 223.35, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 431.11, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 595.95, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 496.41, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 346.16, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 504.02, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 475.49, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 557.91, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 367.71, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 346.16, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ISOSORBIDE DINITRATE 10 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68084008201", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ISOSORBIDE DINITRATE 20 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68084008301", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ISOSORBIDE DINITRATE 30 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "49884000901", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ISOSORBIDE DINITRATE 40 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00187019201", "type": "NDC" } ], "standard_charges": [ { "minimum": 12.88, "maximum": 42.97, "gross_charge": 45.71, "discounted_cash": 25.14, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.51, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.96, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.57, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.72, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.3, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.94, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.38, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.33, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.97, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.22, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.88, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.85, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.28, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.1, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.08, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.97, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.79, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.96, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.34, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.28, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.22, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.51, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.96, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ISOSORBIDE DINITRATE 5 MG PO TABS", "drug_information": { "unit": "2.000000", "type": "UN" }, "code_information": [ { "code": "50268044715", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed 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"methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ISOSORBIDE MONONITRATE 20 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00228262011", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ISOSORBIDE MONONITRATE ER 30 MG PO TB24", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687078301", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ISOSORBIDE MONONITRATE ER 60 MG PO TB24", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00904645061", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ISOSULFAN BLUE 1 % SC SOLN", "drug_information": { "unit": "0.500000", "type": "UN" }, "code_information": [ { "code": "67457022005", "type": "NDC" } ], "standard_charges": [ { "minimum": 4.66, "maximum": 3576.66, "gross_charge": 3804.96, "discounted_cash": 2092.73, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2206.88, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.66, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3043.97, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3222.8, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1107.24, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1826.38, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2279.17, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2275.37, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3576.66, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3348.36, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1072.24, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3234.22, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2853.72, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1340.49, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2587.37, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3576.66, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2979.28, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.29, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3024.94, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2853.72, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3348.36, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2206.88, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.66, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "ISOTRETINOIN 10 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00378661193", "type": "NDC" } ], "standard_charges": [ { "minimum": 3.9, "maximum": 13.02, "gross_charge": 13.85, "discounted_cash": 7.62, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.03, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.56, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.08, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.73, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.03, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.65, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.3, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.28, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.02, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.19, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.9, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.77, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.39, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.88, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.42, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.02, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.84, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.56, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.01, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.39, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.19, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.03, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.56, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ISOTRETINOIN 20 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00378661293", "type": "NDC" } ], "standard_charges": [ { "minimum": 3.49, "maximum": 11.66, "gross_charge": 12.4, "discounted_cash": 6.82, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.19, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.77, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.92, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.61, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.95, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.43, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.42, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.66, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.91, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.49, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.54, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.3, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.43, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.66, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.71, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.77, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.86, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.3, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.91, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.19, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.77, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ISOTRETINOIN 30 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00555105686", "type": "NDC" } ], "standard_charges": [ { "minimum": 4.02, "maximum": 13.41, "gross_charge": 14.27, "discounted_cash": 7.85, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.28, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.79, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.42, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.09, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.15, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.85, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.55, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.53, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.41, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.56, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.02, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.13, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.7, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.03, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.7, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.41, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.17, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.79, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.34, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.7, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.56, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.28, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.79, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ISOTRETINOIN 40 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00378661493", "type": "NDC" } ], "standard_charges": [ { "minimum": 5.38, "maximum": 17.95, "gross_charge": 19.1, "discounted_cash": 10.51, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.08, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.43, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.28, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.18, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.56, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.17, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.44, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.42, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.95, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.81, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.38, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.24, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.33, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.73, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.99, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.95, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.96, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.43, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.33, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.81, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.08, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.43, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ISRADIPINE 1 MG/ML ORAL SUSPENSION", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "P1625254000", "type": "NDC" } ], "standard_charges": [ { "minimum": 6.29, "maximum": 20.98, "gross_charge": 22.32, "discounted_cash": 12.28, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.95, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.19, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.86, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.91, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.5, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.71, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.37, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.35, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.98, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.64, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.29, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.97, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.74, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.86, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.18, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.98, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.48, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.19, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.74, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.74, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.64, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.95, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.19, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ISRADIPINE 2.5 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "16252053901", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ISRADIPINE 5 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "64850091101", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.7, "maximum": 5.66, "gross_charge": 6.02, "discounted_cash": 3.31, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.49, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.29, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.82, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.1, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.75, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.89, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.61, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.6, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.66, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.3, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.7, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.12, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.52, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.12, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.09, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.66, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.71, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.29, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.79, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.52, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.3, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.49, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.29, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ITRACONAZOLE 10 MG/ML PO SOLN", "drug_information": { "unit": "150.000000", "type": "UN" }, "code_information": [ { "code": "31722000631", "type": "NDC" } ], "standard_charges": [ { "minimum": 95.23, "maximum": 317.67, "gross_charge": 337.95, "discounted_cash": 185.87, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 196.01, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 184.52, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 270.36, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 286.24, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 98.34, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 162.22, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 202.43, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 202.09, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 317.67, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 297.4, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 95.23, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 287.26, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 253.46, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 119.06, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 229.81, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 317.67, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 264.61, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 184.52, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 268.67, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 253.46, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 297.4, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 196.01, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 184.52, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ITRACONAZOLE 100 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687029925", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.54, "maximum": 5.12, "gross_charge": 5.45, "discounted_cash": 3.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.16, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.98, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.36, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.62, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.59, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.62, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.26, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.26, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.12, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.54, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.63, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.09, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.71, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.12, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.27, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.98, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.33, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.09, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.16, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.98, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "IVABRADINE HCL 5 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "55513080060", "type": "NDC" } ], "standard_charges": [ { "minimum": 6.34, "maximum": 21.15, "gross_charge": 22.5, "discounted_cash": 12.38, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.05, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.29, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.06, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.55, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.48, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.46, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.15, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.34, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.13, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.88, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.93, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.3, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.15, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.62, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.29, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.89, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.88, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.05, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.29, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "IVERMECTIN 3 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "42799080601", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.19, "maximum": 7.29, "gross_charge": 7.76, "discounted_cash": 4.27, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.5, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.24, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.21, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.57, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.26, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.72, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.65, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.29, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.83, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.19, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.6, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.82, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.73, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.28, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.29, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.08, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.24, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.17, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.82, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.83, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.5, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.24, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "IXABEPILONE 15 MG IV SOLR", "drug_information": { "unit": "7.500000", "type": "UN" }, "code_information": [ { "code": "70020191001", "type": "NDC" } ], "standard_charges": [ { "minimum": 73.2, "maximum": 5569.67, "gross_charge": 5925.18, "discounted_cash": 3258.85, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3436.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 73.2, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4740.14, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5018.63, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1724.23, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2844.09, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3549.18, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 3543.26, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5569.67, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5214.16, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1669.72, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5036.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4443.89, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2087.44, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4029.12, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5569.67, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4639.42, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 98.82, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4710.52, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4443.89, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5214.16, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3436.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 73.2, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "JAPANESE ENCEPHALITIS VAC INAC IM SUSP", "drug_information": { "unit": "0.500000", "type": "UN" }, "code_information": [ { "code": "42515000201", "type": "NDC" } ], "standard_charges": [ { "minimum": 324.18, "maximum": 1081.38, "gross_charge": 1150.4, "discounted_cash": 632.72, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 667.23, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 628.12, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 920.32, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 974.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 334.77, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 552.19, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 689.09, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 687.94, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1081.38, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1012.35, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 324.18, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 977.84, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 862.8, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 405.29, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 782.27, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1081.38, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 900.76, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 628.12, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 914.57, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 862.8, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1012.35, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 667.23, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 628.12, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Jaw arthroscopy/surgery", "code_information": [ { "code": "29800", "type": "HCPCS" }, { "code": "29804", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2391.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1771.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 10033.47, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 18205.9, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2391.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 18205.9, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "JUVEDERM ULTRA 0.4 ML", "drug_information": { "unit": "0.400000", "type": "UN" }, "code_information": [ { "code": "99888000064", "type": "NDC" } ], "standard_charges": [ { "minimum": 208.6, "maximum": 1158.0, "gross_charge": 740.25, "discounted_cash": 407.14, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 429.35, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 404.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 642.54, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 215.41, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 355.32, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 443.41, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 442.67, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 695.84, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 651.42, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 208.6, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 629.21, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 555.19, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 260.79, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 503.37, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 695.84, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 579.62, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 404.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 588.5, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 555.19, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 651.42, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 429.35, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 404.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "JUVEDERM ULTRA PLUS 0.4 ML", "drug_information": { "unit": "0.400000", "type": "UN" }, "code_information": [ { "code": "99888000065", "type": "NDC" } ], "standard_charges": [ { "minimum": 229.31, "maximum": 1158.0, "gross_charge": 813.75, "discounted_cash": 447.56, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 471.98, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 444.31, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 706.34, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 236.8, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 390.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 487.44, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 486.62, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 764.93, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 716.1, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 229.31, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 691.69, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 610.31, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 286.68, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 553.35, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 764.93, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 637.17, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 444.31, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 646.93, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 610.31, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 716.1, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 471.98, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 444.31, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "JUVEDERM ULTRA PLUS XC 0.4 ML", "drug_information": { "unit": "0.400000", "type": "UN" }, "code_information": [ { "code": "99888000067", "type": "NDC" } ], "standard_charges": [ { "minimum": 288.0, "maximum": 1158.0, "gross_charge": 1022.0, "discounted_cash": 562.1, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 592.76, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 558.01, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 887.1, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 297.4, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 490.56, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 612.18, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 611.16, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 960.68, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 899.36, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 288.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 868.7, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 766.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 360.05, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 694.96, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 960.68, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 800.23, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 558.01, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 812.49, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 766.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 899.36, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 592.76, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 558.01, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "JUVEDERM ULTRA PLUS XC 1 ML", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "04444000067", "type": "NDC" } ], "standard_charges": [ { "minimum": 350.0, "maximum": 1167.48, "gross_charge": 1242.0, "discounted_cash": 683.1, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 720.36, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 678.13, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1078.06, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 361.42, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 596.16, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 743.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 742.72, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1167.48, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1092.96, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 350.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1055.7, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 931.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 437.56, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 844.56, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1167.48, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 972.49, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 678.13, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 987.39, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 931.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1092.96, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 720.36, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 678.13, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "JUVEDERM ULTRA XC 0.4 ML", "drug_information": { "unit": "0.400000", "type": "UN" }, "code_information": [ { "code": "99888000066", "type": "NDC" } ], "standard_charges": [ { "minimum": 229.31, "maximum": 1158.0, "gross_charge": 813.75, "discounted_cash": 447.56, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 471.98, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 444.31, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 706.34, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 236.8, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 390.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 487.44, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 486.62, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 764.93, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 716.1, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 229.31, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 691.69, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 610.31, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 286.68, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 553.35, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 764.93, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 637.17, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 444.31, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 646.93, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 610.31, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 716.1, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 471.98, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 444.31, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "JUVEDERM ULTRA XC 1 ML", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "04444000039", "type": "NDC" } ], "standard_charges": [ { "minimum": 350.0, "maximum": 1167.48, "gross_charge": 1242.0, "discounted_cash": 683.1, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 720.36, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 678.13, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1078.06, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 361.42, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 596.16, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 743.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 742.72, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1167.48, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1092.96, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 350.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1055.7, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 931.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 437.56, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 844.56, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1167.48, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 972.49, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 678.13, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 987.39, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 931.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1092.96, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 720.36, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 678.13, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "JUVEDERM VOLLURE 1ML", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "99888000071", "type": "NDC" } ], "standard_charges": [ { "minimum": 411.43, "maximum": 1372.4, "gross_charge": 1460.0, "discounted_cash": 803.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 846.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 797.16, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1267.28, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 424.86, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 700.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 874.54, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 873.08, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1372.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1284.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 411.43, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1241.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1095.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 514.36, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 992.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1372.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1143.18, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 797.16, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1160.7, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1095.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1284.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 846.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 797.16, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "JUVEDERM VOLUMA 1 ML", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "99888000068", "type": "NDC" } ], "standard_charges": [ { "minimum": 199.23, "maximum": 1158.0, "gross_charge": 707.0, "discounted_cash": 388.85, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 410.06, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 386.02, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 613.68, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 205.74, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 339.36, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 423.49, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 422.79, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 664.58, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 622.16, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 199.23, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 600.95, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 530.25, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 249.08, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 480.76, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 664.58, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 553.58, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 386.02, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 562.07, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 530.25, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 622.16, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 410.06, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 386.02, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "K PHOS MONO-SOD PHOS DI & MONO 155-852-130 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "R6498010401", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "KETAMINE 1000 MG/100 ML NS DRIP RTU (ADULT ICU SEDATION)", "drug_information": { "unit": "100.000000", "type": "UN" }, "code_information": [ { "code": "71266908101", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "KETAMINE 1000 MG/100 ML NS DRIP RTU (ADULT STATUS EPILEPTICUS)", "drug_information": { "unit": "100.000000", "type": "UN" }, "code_information": [ { "code": "71266908101_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "KETAMINE HCL 10 MG/ML (IV FOR PO)", "drug_information": { "unit": "50.000000", "type": "UN" }, "code_information": [ { "code": "08252000119", "type": "NDC" } ], "standard_charges": [ { "minimum": 17.93, "maximum": 1158.0, "gross_charge": 63.63, "discounted_cash": 35.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.91, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.74, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.23, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.52, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.54, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.11, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.05, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.81, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.99, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.93, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.09, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.72, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.42, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.27, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.81, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.82, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.74, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.59, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.72, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.99, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.91, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.74, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "KETAMINE HCL 10 MG/ML IJ SOLN", "drug_information": { "unit": "20.000000", "type": "UN" }, "code_information": [ { "code": "42023011310", "type": "NDC" } ], "standard_charges": [ { "minimum": 12.68, "maximum": 1158.0, "gross_charge": 45.0, "discounted_cash": 24.75, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.1, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.06, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.1, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.91, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.3, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.68, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.25, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.85, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.6, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.3, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.24, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.78, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.1, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "KETAMINE HCL 100 MG/ML IJ SOLN", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "00143950910", "type": "NDC" } ], "standard_charges": [ { "minimum": 12.68, "maximum": 1158.0, "gross_charge": 45.0, "discounted_cash": 24.75, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.1, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.06, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.1, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.91, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.3, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.68, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.25, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.85, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.6, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.3, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.24, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.78, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.1, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "KETAMINE HCL 50 MG/5ML IJ SOSY", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "69374098255", "type": "NDC" } ], "standard_charges": [ { "minimum": 12.68, "maximum": 42.3, "gross_charge": 45.0, "discounted_cash": 24.75, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.1, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.12, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.1, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.91, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.3, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.68, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.25, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.85, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.6, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.3, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.24, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.78, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.1, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "KETAMINE HCL 50 MG/5ML IV SOSY", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "73177015602", "type": "NDC" } ], "standard_charges": [ { "minimum": 12.68, "maximum": 42.3, "gross_charge": 45.0, "discounted_cash": 24.75, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.1, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.12, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.1, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.91, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.3, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.68, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.25, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.85, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.6, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", 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"additional_payer_notes": "N/A", "standard_charge_dollar": 39.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.1, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "KETAMINE HCL 50 MG/ML IJ SOLN", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "42023011410", "type": "NDC" } ], "standard_charges": [ { "minimum": 12.68, "maximum": 1158.0, "gross_charge": 45.0, "discounted_cash": 24.75, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.1, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.06, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.1, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.91, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.3, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.68, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.25, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.85, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.6, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.3, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.24, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.78, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.1, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "KETAMINE HCL-SODIUM CHLORIDE 50-0.9 MG/5ML-% IV SOSY", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "70092911944", "type": "NDC" } ], "standard_charges": [ { "minimum": 12.68, "maximum": 42.3, "gross_charge": 45.0, "discounted_cash": 24.75, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.1, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.12, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.1, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.91, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.3, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.68, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.25, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.85, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.6, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.3, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.24, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.78, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.1, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "KETAMINE HCL-SODIUM CHLORIDE 50-0.9 MG/5ML-% IV SOSY (MULTI GPI)", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "73177015602_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 12.68, "maximum": 42.3, "gross_charge": 45.0, "discounted_cash": 24.75, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.1, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.12, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.1, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.91, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.3, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.68, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.25, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.85, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.6, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.3, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.24, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.78, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.1, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "KETOCONAZOLE 2 % EX CREA", "drug_information": { "unit": "15.000000", "type": "GR" }, "code_information": [ { "code": "00168009915", "type": "NDC" } ], "standard_charges": [ { "minimum": 8.22, "maximum": 27.43, "gross_charge": 29.18, "discounted_cash": 16.05, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.92, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.93, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.34, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.72, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.49, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.01, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.48, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.45, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.43, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.68, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.22, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.8, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.89, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.28, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.84, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.43, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.85, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.93, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.89, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.68, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.92, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.93, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "KETOCONAZOLE 2 % EX SHAM", "drug_information": { "unit": "120.000000", "type": "UN" }, "code_information": [ { "code": "45802046564", "type": "NDC" } ], "standard_charges": [ { "minimum": 7.92, "maximum": 26.41, "gross_charge": 28.1, "discounted_cash": 15.46, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.3, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.34, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.48, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.8, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.18, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.49, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.83, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.8, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.41, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.73, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.92, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.89, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.08, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.9, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.11, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.41, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.0, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.34, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.34, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.08, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.73, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.3, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.34, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "KETOCONAZOLE 200 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "51672402601", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "KETOROLAC TROMETHAMINE 0.4 % OP SOLN", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "00023927705", "type": "NDC" } ], "standard_charges": [ { "minimum": 289.07, "maximum": 964.25, "gross_charge": 1025.8, "discounted_cash": 564.19, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 594.96, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 560.09, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 820.64, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 868.85, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 298.51, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 492.38, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 614.45, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 613.43, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 964.25, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 902.7, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 289.07, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 871.93, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 769.35, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 361.39, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 697.54, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 964.25, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 803.2, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 560.09, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 815.51, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 769.35, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 902.7, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 594.96, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 560.09, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "KETOROLAC TROMETHAMINE 0.5 % OP SOLN", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "60505100301", "type": "NDC" } ], "standard_charges": [ { "minimum": 20.46, "maximum": 68.24, "gross_charge": 72.6, "discounted_cash": 39.93, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.11, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.64, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 58.08, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.49, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.13, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.85, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.49, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.41, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 68.24, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.89, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.46, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.71, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.45, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.58, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.37, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 68.24, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 56.85, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.64, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 57.72, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.45, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.89, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.11, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.64, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "KETOROLAC TROMETHAMINE 10 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00093031401", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "KETOROLAC TROMETHAMINE 15 MG/ML IJ SOLN", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68462075525_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.37, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.37, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.5, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.37, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "KETOROLAC TROMETHAMINE 15 MG/ML IJ SOLN|DISCARDED DRUG NOT ADMINISTERED", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68462075525", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.37, "maximum": 1.66, "gross_charge": 1.77, "discounted_cash": 0.97, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.03, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.37, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.42, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.52, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.85, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.06, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.06, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.66, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.56, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.5, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.33, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.62, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.66, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.39, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.5, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.33, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.56, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.03, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.37, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "KETOROLAC TROMETHAMINE 30 MG/ML IJ SOLN", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "25021070101_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.37, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.37, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.5, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.37, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "KETOROLAC TROMETHAMINE 30 MG/ML IJ SOLN|DISCARDED DRUG NOT ADMINISTERED", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "25021070101", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.37, "maximum": 1.47, "gross_charge": 1.56, "discounted_cash": 0.86, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.9, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.37, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.25, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.32, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.45, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.93, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.93, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.47, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.37, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.44, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.33, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.17, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.55, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.06, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.47, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.22, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.5, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.24, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.17, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.37, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.9, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.37, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "KETOTIFEN FUMARATE 0.035 % OP SOLN", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "00536125240", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Kidney endoscopy", "code_information": [ { "code": "50551", "type": "HCPCS" }, { "code": "50553", "type": "HCPCS" }, { "code": "50575", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 3747.14, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2775.66, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 23825.31, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 43231.44, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3747.14, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 43231.44, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Kidney endoscopy & treatment", "code_information": [ { "code": "50557", "type": "HCPCS" }, { "code": "50561", "type": "HCPCS" }, { "code": "50580", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 6816.07, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5048.94, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2775.66, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 18888.78, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 34274.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6816.07, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3747.14, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 34274.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Knee arthroscopy dx", "code_information": [ { "code": "29870", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2391.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1771.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 6596.21, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 11968.93, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2391.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 11968.93, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Knee arthroscopy/surgery", "code_information": [ { "code": "29851", "type": "HCPCS" }, { "code": "29873", "type": "HCPCS" }, { "code": "29874", "type": "HCPCS" }, { "code": "29875", "type": "HCPCS" }, { "code": "29876", "type": "HCPCS" }, { "code": "29877", "type": "HCPCS" }, { "code": "29879", "type": "HCPCS" }, { "code": "29880", "type": "HCPCS" }, { "code": "29881", "type": "HCPCS" }, { "code": "29882", "type": "HCPCS" }, { "code": "29883", "type": "HCPCS" }, { "code": "29884", "type": "HCPCS" }, { "code": "29886", "type": "HCPCS" }, { "code": "29888", "type": "HCPCS" }, { "code": "29889", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 9484.13, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", 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"Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 33967.6, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1179.66, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2391.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5265.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 9484.13, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 33967.6, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "L colectomy/coloproctostomy", "code_information": [ { "code": "44207", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 44157.31, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 81616.36, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 81616.36, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "L hrt art/grft angio", "code_information": [ { "code": "93459", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2370.82, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1756.16, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 15847.46, "methodology": "percent of total billed charges" }, { "payer_name": 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"plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1756.16, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 12139.91, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 22028.1, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2370.82, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 22028.1, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "L hrt cath chd nm/abn nt cnj", "code_information": [ { "code": "93595", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2370.82, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1756.16, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 28658.64, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, 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"standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 232.07, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 368.93, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 123.68, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 204.01, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 254.59, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 254.17, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 399.53, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 374.03, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 119.77, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 361.28, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 318.77, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 149.74, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 289.02, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 399.53, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 332.8, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 232.07, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 337.9, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 318.77, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 374.03, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 246.52, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 232.07, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "L-CYSTEINE HCL 50 MG/ML IV SOLN", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "51754100703_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 70.0, "maximum": 1158.0, "gross_charge": 248.41, "discounted_cash": 136.63, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 144.08, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 135.63, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 215.62, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 72.29, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 119.24, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 148.8, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 148.55, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 233.51, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 218.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 70.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 211.15, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 186.31, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.51, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 168.92, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 233.51, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 194.51, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 135.63, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 197.49, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 186.31, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 218.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 144.08, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 135.63, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LABETALOL 20 MG/ML SUSPENSION", "drug_information": { "unit": "15.000000", "type": "UN" }, "code_information": [ { "code": "P0185011800", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LABETALOL 5 MG/ML 5ML", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "61553033633", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LABETALOL HCL 100 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687043901", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LABETALOL HCL 200 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687045001", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LABETALOL HCL 300 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687046101", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LABETALOL HCL 5 MG/ML IV SOLN", "drug_information": { "unit": "20.000000", "type": "UN" }, "code_information": [ { "code": "72266010201", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LACOSAMIDE 10 MG/ML INFUSION SYRINGE", "drug_information": { "unit": "20.000000", "type": "UN" }, "code_information": [ { "code": "25021079120", "type": "NDC" } ], "standard_charges": [ { "minimum": 12.68, "maximum": 42.3, "gross_charge": 45.0, "discounted_cash": 24.75, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.1, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.12, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.1, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.91, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.3, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.68, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.25, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.85, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.6, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.3, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.24, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.78, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.1, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LACOSAMIDE 10 MG/ML PO SOLN", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "00121202495", "type": "NDC" } ], "standard_charges": [ { "minimum": 30.03, "maximum": 100.19, "gross_charge": 106.58, "discounted_cash": 58.62, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.82, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 58.19, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 85.26, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 90.27, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 51.16, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.84, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.73, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 100.19, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.79, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.03, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 90.59, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 79.94, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.55, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 72.47, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 100.19, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 83.45, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 58.19, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 84.73, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 79.94, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.79, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.82, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 58.19, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LACOSAMIDE 100 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687068757", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.25, "maximum": 7.52, "gross_charge": 8.0, "discounted_cash": 4.4, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.4, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.78, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.33, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.84, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.79, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.25, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.8, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.82, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.44, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.26, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.36, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LACOSAMIDE 200 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00131248035", "type": "NDC" } ], "standard_charges": [ { "minimum": 12.45, "maximum": 41.52, "gross_charge": 44.17, "discounted_cash": 24.29, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.62, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.12, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.34, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.41, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.85, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.46, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.41, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.87, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.45, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.54, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.13, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.56, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.04, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.59, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.12, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.12, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.13, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.87, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.62, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.12, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LACOSAMIDE 200 MG/20ML IV SOLN", "drug_information": { "unit": "20.000000", "type": "UN" }, "code_information": [ { "code": "25021079120_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 12.68, "maximum": 42.3, "gross_charge": 45.0, "discounted_cash": 24.75, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.1, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.12, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.1, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.91, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.3, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.68, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.25, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.85, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.6, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.3, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.24, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.78, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.1, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LACOSAMIDE 50 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687067657", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.25, "maximum": 7.52, "gross_charge": 8.0, "discounted_cash": 4.4, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.4, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.78, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.33, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.84, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.79, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.25, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.8, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.82, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.44, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.26, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.36, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LACTASE 3000 UNITS PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00904522452", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LACTATED RINGERS IV BOLUS", "drug_information": { "unit": "1000.000000", "type": "UN" }, "code_information": [ { "code": "00338011704", "type": "NDC" } ], "standard_charges": [ { "minimum": 19.73, "maximum": 1158.0, "gross_charge": 70.0, "discounted_cash": 38.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.76, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.37, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.93, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.86, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.73, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.66, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.6, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.81, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.65, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LACTATED RINGERS IV BOLUS (REPLACEMENT)", "drug_information": { "unit": "1000.000000", "type": "UN" }, "code_information": [ { "code": "00338011704_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 19.73, "maximum": 1158.0, "gross_charge": 70.0, "discounted_cash": 38.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.76, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.37, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.93, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.86, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.73, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.66, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.6, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.81, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.65, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LACTATED RINGERS IV BOLUS (SEPSIS)", "drug_information": { "unit": "1000.000000", "type": "UN" }, "code_information": [ { "code": "00338011704_3", "type": "NDC" } ], "standard_charges": [ { "minimum": 19.73, "maximum": 1158.0, "gross_charge": 70.0, "discounted_cash": 38.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.76, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.37, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.93, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.86, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.73, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.66, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.6, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.81, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.65, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LACTATED RINGERS IV SOLN", "drug_information": { "unit": "1000.000000", "type": "UN" }, "code_information": [ { "code": "00338011704_4", "type": "NDC" } ], "standard_charges": [ { "minimum": 19.73, "maximum": 1158.0, "gross_charge": 70.0, "discounted_cash": 38.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.76, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.37, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.93, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.86, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.73, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.66, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.6, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.81, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.65, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LACTATED RINGERS IV SOLN (MORGAN LENS)", "drug_information": { "unit": "1000.000000", "type": "UN" }, "code_information": [ { "code": "00338011704_5", "type": "NDC" } ], "standard_charges": [ { "minimum": 19.73, "maximum": 1158.0, "gross_charge": 70.0, "discounted_cash": 38.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.76, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.37, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.93, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.86, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.73, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.66, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.6, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.81, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.65, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LACTIC AC-CITRIC AC-POT BITART 1.8-1-0.4 % VA GEL", "drug_information": { "unit": "5.000000", "type": "GR" }, "code_information": [ { "code": "69751010012", "type": "NDC" } ], "standard_charges": [ { "minimum": 18.52, "maximum": 61.77, "gross_charge": 65.71, "discounted_cash": 36.14, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.11, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.88, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.57, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.66, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.12, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.54, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.36, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.29, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.77, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 57.82, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.52, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.85, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.28, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.15, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 44.68, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.77, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 51.45, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.88, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.24, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.28, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 57.82, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.11, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.88, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LACTINEX PO PACK", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "08290236712", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LACTOBACILLUS RHAMNOSUS (GG) PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "49100040007", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LACTULOSE 10 GM/15ML PO SOLN", "drug_information": { "unit": "30.000000", "type": "UN" }, "code_information": [ { "code": "00121115440", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Lam facetec & foramot crv", "code_information": [ { "code": "63045", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 5265.64, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3900.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 23808.33, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 43200.62, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5265.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 43200.62, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Lam facetec & foramot lumbar", "code_information": [ { "code": "63047", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 5265.64, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3900.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 18824.21, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 34156.84, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5265.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 34156.84, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Lam facetec & foramot thrc", "code_information": [ { "code": "63046", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 5265.64, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3900.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 21477.1, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 38970.55, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5265.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 38970.55, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LAMINARIA # 10", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "08252000147", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 1158.0, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.72, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LAMINARIA # 2", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "08252000145", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 1158.0, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.72, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LAMINARIA # 3", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "08252000146", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 1158.0, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.72, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LAMINARIA # 4", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "04444000028", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 1158.0, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.72, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LAMINARIA # 5", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "04444000029", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 1158.0, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.72, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LAMINARIA # 6", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "04444000030", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 1158.0, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.72, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LAMINARIA # 8", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "04444000032", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 1158.0, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.72, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Laminotomy single lumbar", "code_information": [ { "code": "63042", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 5265.64, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3900.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 19700.41, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 35759.18, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5265.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 35759.18, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LAMIVUDINE 10 MG/ML PO SOLN", "drug_information": { "unit": "240.000000", "type": "UN" }, "code_information": [ { "code": "57237027424", "type": "NDC" } ], "standard_charges": [ { "minimum": 34.46, "maximum": 114.96, "gross_charge": 122.3, "discounted_cash": 67.27, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 70.93, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 66.78, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 97.84, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.59, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.59, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 58.7, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 73.26, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 73.14, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 114.96, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 107.62, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.46, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.96, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 91.73, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 83.16, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 114.96, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 95.76, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 66.78, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 97.23, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 91.73, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 107.62, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 70.93, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 66.78, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LAMIVUDINE 100 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60505325006", "type": "NDC" } ], "standard_charges": [ { "minimum": 5.21, "maximum": 17.39, "gross_charge": 18.5, "discounted_cash": 10.18, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.73, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.1, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.67, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.38, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.88, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.08, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.06, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.39, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.28, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.21, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.73, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.88, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.52, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.58, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.39, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.49, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.1, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.71, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.88, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.28, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.73, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.1, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LAMIVUDINE 150 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687072021", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.63, "maximum": 8.78, "gross_charge": 9.34, "discounted_cash": 5.14, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.42, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.1, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.47, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.91, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.48, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.59, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.59, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.78, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.22, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.63, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.94, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.01, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.29, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.35, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.78, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.31, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.1, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.43, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.01, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.22, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.42, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.1, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LAMIVUDINE 300 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "49702020413", "type": "NDC" } ], "standard_charges": [ { "minimum": 8.84, "maximum": 29.5, "gross_charge": 31.38, "discounted_cash": 17.26, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.13, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.1, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.58, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.13, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.06, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.8, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.77, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.5, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.61, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.84, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.67, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.54, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.06, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.34, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.5, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.57, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.13, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.95, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.54, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.61, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.13, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LAMIVUDINE-ZIDOVUDINE 150-300 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "31722050660", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LAMOTRIGINE 100 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68084031901", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", 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"plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LAMOTRIGINE 150 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687069301", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LAMOTRIGINE 200 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687070401", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LAMOTRIGINE 25 MG PO CHEW", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "16571078601", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LAMOTRIGINE 25 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68084031801", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LAMOTRIGINE 5 MG PO CHEW", "drug_information": { "unit": "2.000000", "type": "UN" }, "code_information": [ { "code": "68462022801", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LAMOTRIGINE ER 100 MG PO TB24", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68382098106", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LAMOTRIGINE ER 200 MG PO TB24", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68382098206", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LAMOTRIGINE ER 25 MG PO TB24", "drug_information": { "unit": "2.000000", "type": "UN" }, "code_information": [ { "code": "68382097906", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LAMOTRIGINE ER 250 MG PO TB24", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68382098306", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.27, "maximum": 4.25, "gross_charge": 4.52, "discounted_cash": 2.49, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.62, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.47, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.62, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.83, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.32, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.17, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.71, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.7, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.25, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.98, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.84, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.59, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.07, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.25, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.54, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.47, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.59, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.98, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.62, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.47, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LAMOTRIGINE ER 300 MG PO TB24", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "55111042830", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.59, "maximum": 8.64, "gross_charge": 9.19, "discounted_cash": 5.05, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.33, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.02, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.35, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.78, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.67, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.41, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.5, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.5, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.64, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.09, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.59, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.81, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.89, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.24, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.25, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.64, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.2, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.02, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.31, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.89, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.09, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.33, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.02, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LAMOTRIGINE ER 50 MG PO TB24", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "13668034030", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LANREOTIDE ACETATE 120 MG/0.5ML SC SOLN", "drug_information": { "unit": "0.500000", "type": "UN" }, "code_information": [ { "code": "69097087067", "type": "NDC" } ], "standard_charges": [ { "minimum": 3409.95, "maximum": 11374.58, "gross_charge": 12100.62, "discounted_cash": 6655.34, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 7018.36, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 6606.94, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9680.5, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10249.23, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3521.28, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5808.3, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7248.27, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 7236.17, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11374.58, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10648.55, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3409.95, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10285.53, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9075.47, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 4263.05, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 8228.42, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 11374.58, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 9474.79, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6606.94, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 9619.99, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9075.47, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10648.55, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7018.36, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6606.94, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LANREOTIDE ACETATE 60 MG/0.2ML SC SOLN", "drug_information": { "unit": "0.200000", "type": "UN" }, "code_information": [ { "code": "15054106004", "type": "NDC" } ], "standard_charges": [ { "minimum": 27.28, "maximum": 14303.04, "gross_charge": 15216.0, "discounted_cash": 8368.8, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 8825.28, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12172.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12887.95, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4427.86, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7303.68, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 9114.38, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 9099.17, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14303.04, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13390.08, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 4287.87, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12933.6, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11412.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 5360.6, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 10346.88, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 14303.04, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 11914.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.83, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 12096.72, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11412.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13390.08, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8825.28, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "LANSOPRAZOLE 15 MG PO CPDR", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00378801593", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LANSOPRAZOLE 15 MG PO TBDD", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "64764054311", "type": "NDC" } ], "standard_charges": [ { "minimum": 8.83, "maximum": 29.45, "gross_charge": 31.33, "discounted_cash": 17.23, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.17, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.11, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.06, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.54, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.12, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.04, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.77, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.74, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.45, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.57, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.83, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.63, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.04, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.3, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.45, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.53, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.11, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.91, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.57, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.17, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.11, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LANSOPRAZOLE 3 MG/ML PO SUSP", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "65628008003", "type": "NDC" } ], "standard_charges": [ { "minimum": 6.2, "maximum": 20.69, "gross_charge": 22.01, "discounted_cash": 12.11, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.77, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.02, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.61, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.64, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.4, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.56, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.18, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.16, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.69, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.37, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.2, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.71, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.51, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.97, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.69, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.23, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.02, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.5, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.51, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.37, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.77, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.02, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LANSOPRAZOLE 30 MG PO CPDR", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00093735156", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.2, "maximum": 4.01, "gross_charge": 4.27, "discounted_cash": 2.35, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.48, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.33, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.42, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.62, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.24, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.05, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.56, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.55, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.01, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.2, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.63, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.5, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.9, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.01, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.34, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.33, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.48, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.33, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LANSOPRAZOLE 30 MG PO TBDD", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "64764054411", "type": "NDC" } ], "standard_charges": [ { "minimum": 8.83, "maximum": 29.45, "gross_charge": 31.33, "discounted_cash": 17.23, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.17, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.11, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.06, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.54, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.12, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.04, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.77, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.74, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.45, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.57, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.83, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.63, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.04, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.3, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.45, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.53, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.11, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.91, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.57, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.17, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.11, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LANTHANUM CARBONATE 1000 MG PO CHEW", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "54092025490", "type": "NDC" } ], "standard_charges": [ { "minimum": 7.66, "maximum": 25.56, "gross_charge": 27.19, "discounted_cash": 14.95, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.77, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.85, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.75, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.03, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.91, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.05, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.29, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.26, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.56, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.93, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.66, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.11, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.39, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.58, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.49, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.56, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.29, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.85, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.62, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.39, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.93, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.77, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.85, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LANTHANUM CARBONATE 500 MG PO CHEW", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "54092025290", "type": "NDC" } ], "standard_charges": [ { "minimum": 7.66, "maximum": 25.56, "gross_charge": 27.19, "discounted_cash": 14.95, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.77, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.85, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.75, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.03, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.91, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.05, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.29, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.26, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.56, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.93, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.66, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.11, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.39, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.58, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.49, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.56, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.29, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.85, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.62, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.39, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.93, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.77, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.85, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Lap colectomy part w/ileum", "code_information": [ { "code": "44205", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 44155.6, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 83641.35, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 83641.35, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Lap enterolysis", "code_information": [ { "code": "44180", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4300.51, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3185.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 16225.87, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 33054.7, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4300.51, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 33054.7, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Lap gastric bypass/roux-en-y", "code_information": [ { "code": "43644", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 36964.84, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 67267.92, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 67267.92, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Lap ing hernia repair init", "code_information": [ { "code": "49650", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4300.51, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3185.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 13195.12, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 23942.75, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4300.51, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 23942.75, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Lap ing hernia repair recur", "code_information": [ { "code": "49651", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4300.51, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3185.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 20682.45, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 37558.58, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4300.51, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 37558.58, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Lap insert tunnel ip cath", "code_information": [ { "code": "49324", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4300.51, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3185.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 10414.58, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 18897.41, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4300.51, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 18897.41, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Lap myotomy heller", "code_information": [ { "code": "43279", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 22676.04, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 41146.05, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 41146.05, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Lap paraesoph her rpr w/mesh", "code_information": [ { "code": "43282", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 7674.11, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5684.53, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 19658.29, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 35670.32, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7674.11, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 35670.32, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Lap paraesophag hern repair", "code_information": [ { "code": "43281", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 7674.11, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5684.53, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 25959.84, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 47104.6, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7674.11, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 47104.6, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Lap place gastr adj device", "code_information": [ { "code": "43770", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 7674.11, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5684.53, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 7044.47, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 12782.31, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7674.11, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 12782.31, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Lap revision perm ip cath", "code_information": [ { "code": "49325", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4300.51, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3185.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 10979.02, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 19921.62, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4300.51, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 19921.62, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Lap rmvl gastr adj all parts", "code_information": [ { "code": "43774", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2804.32, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2077.27, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 17048.65, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 31120.29, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2804.32, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 31120.29, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Lap rmvl gastr adj device", "code_information": [ { "code": "43772", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2804.32, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2077.27, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 25910.16, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 47014.32, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2804.32, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 47014.32, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Lap sleeve gastrectomy", "code_information": [ { "code": "43775", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 17587.61, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 31913.02, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 31913.02, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Laparo ablate liver tumor rf", "code_information": [ { "code": "47370", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 7674.11, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5684.53, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 39411.51, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 71512.93, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7674.11, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 71512.93, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Laparo ablate renal cyst", "code_information": [ { "code": "50541", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 7674.11, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5684.53, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 18638.91, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 33820.6, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7674.11, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 33820.6, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Laparo cholecystectomy/explr", "code_information": [ { "code": "47564", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 7674.11, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5684.53, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 17755.41, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 32217.51, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7674.11, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 32217.51, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Laparo cholecystectomy/graph", "code_information": [ { "code": "47563", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4300.51, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3185.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 24534.38, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 44517.97, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4300.51, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 44517.97, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Laparo new ureter/bladder", "code_information": [ { "code": "50947", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 7674.11, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5684.53, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 40362.78, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 73238.91, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7674.11, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 73238.91, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Laparo partial colectomy", "code_information": [ { "code": "44204", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 38030.3, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 69006.57, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 69006.57, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Laparo partial nephrectomy", "code_information": [ { "code": "50543", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 7674.11, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5684.53, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 36222.23, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 65725.84, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7674.11, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 65725.84, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Laparo radical nephrectomy", "code_information": [ { "code": "50545", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 28576.17, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 51851.95, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 51851.95, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Laparo sling operation", "code_information": [ { "code": "51992", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4300.51, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3185.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 56292.44, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 102143.58, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4300.51, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 102143.58, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Laparo urethral suspension", "code_information": [ { "code": "51990", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4300.51, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3185.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 33847.43, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 63222.16, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4300.51, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 63222.16, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Laparo-asst vag hysterectomy", "code_information": [ { "code": "58550", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4300.51, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3185.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 15868.39, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 28793.48, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4300.51, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 28793.48, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Laparo-myomectomy complex", "code_information": [ { "code": "58546", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 7674.11, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5684.53, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 40533.53, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 73568.93, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7674.11, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 73568.93, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Laparo-vag hyst incl t/o", "code_information": [ { "code": "58552", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 7674.11, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5684.53, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 25790.04, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 46796.45, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7674.11, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 46796.45, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Laparo-vag hyst w/t/o compl", "code_information": [ { "code": "58554", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 7674.11, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5684.53, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 26595.06, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 49192.06, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7674.11, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 49192.06, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Laparoscope proc rectum", "code_information": [ { "code": "45499", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4300.51, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3185.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 24569.2, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 44581.24, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4300.51, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 44581.24, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Laparoscopic cholecystectomy", "code_information": [ { "code": "47562", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4300.51, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": 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"standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 26546.77, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Laparoscopic myomectomy", "code_information": [ { "code": "58545", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4300.51, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3185.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 30069.05, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 54588.21, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4300.51, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 54588.21, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Laparoscopic nephrectomy", "code_information": [ { "code": "50546", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 52154.56, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 94635.3, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 94635.3, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Laparoscopic proc", "code_information": [ { "code": "45400", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 35042.13, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 63584.5, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 63584.5, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Laparoscopy adrenalectomy", "code_information": [ { "code": "60650", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 22451.08, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 41964.81, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 41964.81, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Laparoscopy appendectomy", "code_information": [ { "code": "44970", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4300.51, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3185.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 15544.2, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 28205.21, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4300.51, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 28205.21, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Laparoscopy aspiration", "code_information": [ { "code": "49322", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4300.51, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3185.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 34041.75, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 62612.83, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4300.51, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 62612.83, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Laparoscopy biopsy", "code_information": [ { "code": "49321", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4300.51, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3185.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 15071.03, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 27353.84, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4300.51, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 27353.84, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Laparoscopy excise lesions", "code_information": [ { "code": "58662", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4300.51, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3185.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 26167.07, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 47480.61, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4300.51, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 47480.61, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Laparoscopy fimbrioplasty", "code_information": [ { "code": "58672", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4300.51, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3185.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 16702.24, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 30306.49, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4300.51, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 30306.49, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Laparoscopy fundoplasty", "code_information": [ { "code": "43280", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 7674.11, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5684.53, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 25464.21, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 46205.25, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7674.11, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 46205.25, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Laparoscopy gastrostomy", "code_information": [ { "code": "43653", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4300.51, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3185.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 18296.06, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 33198.5, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4300.51, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 33198.5, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Laparoscopy lymph node biop", "code_information": [ { "code": "38570", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4300.51, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3185.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 35778.6, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 64920.83, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4300.51, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 64920.83, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Laparoscopy lymphadenectomy", "code_information": [ { "code": "38571", "type": "HCPCS" }, { "code": "38572", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 7674.11, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5684.53, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 34525.15, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 62646.42, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7674.11, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 62646.42, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Laparoscopy lysis", "code_information": [ { "code": "58660", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4300.51, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3185.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 14681.58, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 26639.96, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4300.51, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 26639.96, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Laparoscopy orchiectomy", "code_information": [ { "code": "54690", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4300.51, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3185.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 15596.26, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 28299.64, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4300.51, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 28299.64, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Laparoscopy orchiopexy", "code_information": [ { "code": "54692", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4300.51, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3185.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 15163.09, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 27513.67, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4300.51, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 27513.67, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Laparoscopy pyeloplasty", "code_information": [ { "code": "50544", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 7674.11, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5684.53, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 32894.07, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 59686.81, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7674.11, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 59686.81, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Laparoscopy remove adnexa", "code_information": [ { "code": "58661", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4300.51, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3185.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 16406.2, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 29769.35, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4300.51, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 29769.35, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Laparoscopy splenectomy", "code_information": [ { "code": "38120", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 7674.11, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5684.53, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 30424.66, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 55206.13, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7674.11, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 55206.13, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Laparoscopy surg colpopexy", "code_information": [ { "code": "57425", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 7674.11, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5684.53, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 41375.51, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 75076.54, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7674.11, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 75076.54, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Laparoscopy ureterolithotomy", "code_information": [ { "code": "50945", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4300.51, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3185.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 47702.42, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 86556.8, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4300.51, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 86556.8, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Laparoscopy vagus nerve", "code_information": [ { "code": "43652", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4300.51, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3185.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 42802.85, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 81485.94, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4300.51, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 81485.94, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LAPATINIB DITOSYLATE 250 MG PO TABS", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "00078067119", "type": "NDC" } ], "standard_charges": [ { "minimum": 279.79, "maximum": 933.28, "gross_charge": 992.85, "discounted_cash": 546.07, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 575.85, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 542.1, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 794.28, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 840.94, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 288.92, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 476.57, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 594.72, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 593.72, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 933.28, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 873.71, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 279.79, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 843.92, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 744.64, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 349.78, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 675.14, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 933.28, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 777.4, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 542.1, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 789.32, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 744.64, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 873.71, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 575.85, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 542.1, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Laps abltj uterine fibroids", "code_information": [ { "code": "58674", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 7674.11, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5684.53, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 14020.74, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 25440.85, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7674.11, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 25440.85, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Laps esophgl sphnctr agmntj", "code_information": [ { "code": "43284", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 7674.11, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5684.53, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 28647.33, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 51981.08, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7674.11, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 51981.08, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Laps pelvic lymphadec", "code_information": [ { "code": "38573", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 7674.11, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5684.53, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 26633.8, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 52660.09, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7674.11, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 52660.09, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Laps surg prst8ect rpbic rad", "code_information": [ { "code": "55866", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 7674.11, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5684.53, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 38805.34, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 71271.49, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7674.11, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 71271.49, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Laps surg prst8ect smpl stot", "code_information": [ { "code": "55867", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 7674.11, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5684.53, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 47124.58, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 85508.34, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7674.11, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 85508.34, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Laps tot hyst resj mal", "code_information": [ { "code": "58575", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 58034.87, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 105305.23, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 105305.23, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Largsc w/laser dstrj les", "code_information": [ { "code": "31572", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2717.65, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2013.07, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 10937.79, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 19870.03, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2717.65, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 19870.03, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Largsc w/njx augmentation", "code_information": [ { "code": "31574", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1271.11, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 941.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 11230.69, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 20378.26, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1271.11, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 20378.26, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Largsc w/ther injection", "code_information": [ { "code": "31573", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1271.11, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 941.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 9236.17, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 16759.19, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1271.11, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 16759.19, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Laryngoplasty cricoid split", "code_information": [ { "code": "31587", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4360.43, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3229.95, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 15138.45, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 27479.7, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4360.43, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 27479.7, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Laryngoplasty laryngeal sten", "code_information": [ { "code": "31552", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4360.43, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3229.95, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 16420.87, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 29795.96, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4360.43, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 29795.96, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Laryngoplasty laryngeal web", "code_information": [ { "code": "31580", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4360.43, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3229.95, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 19137.93, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 34886.94, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4360.43, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 34886.94, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Laryngoplasty medialization", "code_information": [ { "code": "31591", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4360.43, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3229.95, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 12623.83, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 22906.15, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4360.43, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 22906.15, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Laryngoscop w/arytenoidectom", "code_information": [ { "code": "31560", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 5102.55, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3779.67, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 13693.47, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 24847.03, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5102.55, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 24847.03, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Laryngoscop w/vc inj + scope", "code_information": [ { "code": "31571", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2717.65, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2013.07, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 12623.83, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 22906.15, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2717.65, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 22906.15, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Laryngoscope w/vc inj", "code_information": [ { "code": "31570", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2717.65, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2013.07, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 11704.02, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 21237.15, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2717.65, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 21237.15, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Laryngoscopy and dilation", "code_information": [ { "code": "31528", "type": "HCPCS" }, { "code": "31529", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2717.65, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2013.07, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 14181.55, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 25732.67, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2717.65, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 25732.67, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Laryngoscopy w/biopsy", "code_information": [ { "code": "31535", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2717.65, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2013.07, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 10782.54, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 19565.1, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2717.65, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 19565.1, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Laryngoscopy w/bx & op scope", "code_information": [ { "code": "31536", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2717.65, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2013.07, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 9636.98, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 17486.46, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2717.65, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 17486.46, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Laryngoscopy w/exc of tumor", "code_information": [ { "code": "31540", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2717.65, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2013.07, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 10040.03, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 18217.83, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2717.65, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 18217.83, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Laryngoscopy w/fb & op scope", "code_information": [ { "code": "31531", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2717.65, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2013.07, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 11178.56, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 20283.67, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2717.65, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 20283.67, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Laryngoscopy with biopsy", "code_information": [ { "code": "31576", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1271.11, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 941.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 10272.49, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 18639.61, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1271.11, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 18639.61, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Larynscop remve cart + scop", "code_information": [ { "code": "31561", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 5102.55, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3779.67, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 17429.24, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 32138.2, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5102.55, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 32138.2, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Larynscop w/tumr exc + scope", "code_information": [ { "code": "31541", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2717.65, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2013.07, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 11878.58, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 21553.9, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2717.65, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 21553.9, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Laser surgery anal lesions", "code_information": [ { "code": "46917", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2021.42, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1497.34, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 11380.92, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 20650.89, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2021.42, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 20650.89, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Laser surgery eye strands", "code_information": [ { "code": "67031", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 404.37, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 299.54, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 1029.52, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 1868.09, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 404.37, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 1868.09, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Laser surgery of cervix", "code_information": [ { "code": "57513", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2343.63, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1736.02, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 5135.23, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 9317.96, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2343.63, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 9317.96, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Laser surgery of prostate", "code_information": [ { "code": "52648", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 3747.14, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2775.66, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 12691.38, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 23028.71, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3747.14, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 23028.71, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Laser treatment of retina", "code_information": [ { "code": "67039", "type": "HCPCS" }, { "code": "67040", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2965.25, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2196.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 8914.69, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 16175.85, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2965.25, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 16175.85, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Lat retinacular release open", "code_information": [ { "code": "27425", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2391.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1771.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 22514.25, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 40852.5, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2391.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 40852.5, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LATANOPROST 0.005 % OP SOLN", "drug_information": { "unit": "2.500000", "type": "UN" }, "code_information": [ { "code": "70069042101", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LECANEMAB-IRMB 200 MG/2ML IV SOLN", "drug_information": { "unit": "2.000000", "type": "UN" }, "code_information": [ { "code": "62856021201", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.73, "maximum": 958.09, "gross_charge": 1019.24, "discounted_cash": 560.58, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 591.16, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.73, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 815.39, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 863.3, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 296.6, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 489.24, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 610.52, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 609.51, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 958.09, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 896.93, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 287.22, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 866.35, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 764.43, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 359.08, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 693.08, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 958.09, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 798.06, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.99, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 810.3, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 764.43, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 896.93, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 591.16, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.73, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "LECANEMAB-IRMB 500 MG/5ML IV SOLN", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "62856021501", "type": "NDC" } ], "standard_charges": [ { "minimum": 718.05, "maximum": 2395.2, "gross_charge": 2548.08, "discounted_cash": 1401.44, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1477.89, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1391.25, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2038.46, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2158.22, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 741.49, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1223.08, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1526.3, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 1523.75, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2395.2, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2242.31, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 718.05, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2165.87, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1911.06, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 897.69, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1732.69, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2395.2, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1995.15, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1391.25, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2025.72, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1911.06, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2242.31, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1477.89, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1391.25, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LEECH (MEDICINAL)", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "04444000007", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.62, "maximum": 1158.0, "gross_charge": 41.25, "discounted_cash": 22.69, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.93, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.52, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.81, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.0, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.71, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.67, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.78, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.3, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.62, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.06, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.94, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.53, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.05, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.78, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.3, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.52, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.79, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.94, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.3, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.93, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.52, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LEFLUNOMIDE 10 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60505250201", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.7, "maximum": 5.68, "gross_charge": 6.04, "discounted_cash": 3.32, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.5, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.3, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.83, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.12, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.76, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.9, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.62, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.61, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.68, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.32, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.7, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.13, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.53, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.13, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.11, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.68, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.73, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.3, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.53, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.32, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.5, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.3, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LEFLUNOMIDE 20 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "50268047815", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Lefort i-1 piece w/ graft", "code_information": [ { "code": "21145", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 31648.74, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 57427.16, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 57427.16, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Lefort i-1 piece w/o graft", "code_information": [ { "code": "21141", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4360.43, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3229.95, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 37601.02, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 68329.77, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4360.43, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 68329.77, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Lefort i-2 piece w/ graft", "code_information": [ { "code": "21146", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 18017.52, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 32788.85, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 32788.85, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Lefort i-2 piece w/o graft", "code_information": [ { "code": "21142", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4360.43, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3229.95, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 45674.15, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 82876.51, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4360.43, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 82876.51, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Lefort i-3/> piece w/ graft", "code_information": [ { "code": "21147", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 35357.85, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 64208.42, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 64208.42, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Lefort i-3/> piece w/o graft", "code_information": [ { "code": "21143", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4360.43, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3229.95, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 31751.94, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 57868.04, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4360.43, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 57868.04, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Left hrt cath w/ventrclgrphy", "code_information": [ { "code": "93452", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2370.82, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1756.16, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 19394.57, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 35191.76, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2370.82, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 35191.76, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Lengthening of hand tendon", "code_information": [ { "code": "26478", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2391.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1771.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 36083.57, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 65474.21, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2391.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 65474.21, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Lengthening of thigh bone", "code_information": [ { "code": "27466", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 60273.05, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 109366.41, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 109366.41, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Lengthening of thigh tendon", "code_information": [ { "code": "27393", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 5265.64, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3900.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 22360.75, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 40598.89, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5265.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 40598.89, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Lengthening of thigh tendons", "code_information": [ { "code": "27394", "type": "HCPCS" }, { "code": "27395", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 5265.64, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3900.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1771.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 21493.72, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 39000.7, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5265.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2391.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 39000.7, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LETERMOVIR 240 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00006307504", "type": "NDC" } ], "standard_charges": [ { "minimum": 294.56, "maximum": 982.56, "gross_charge": 1045.28, "discounted_cash": 574.9, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 606.26, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 570.72, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 836.22, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 885.35, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 304.18, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 501.73, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 626.12, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 625.08, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 982.56, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 919.85, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 294.56, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 888.49, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 783.96, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 368.25, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 710.79, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 982.56, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 818.45, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 570.72, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 831.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 783.96, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 919.85, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 606.26, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 570.72, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LETERMOVIR 480 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00006307604", "type": "NDC" } ], "standard_charges": [ { "minimum": 294.56, "maximum": 982.56, "gross_charge": 1045.28, "discounted_cash": 574.9, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 606.26, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 570.72, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 836.22, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 885.35, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 304.18, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 501.73, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 626.12, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 625.08, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 982.56, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 919.85, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 294.56, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 888.49, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 783.96, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 368.25, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 710.79, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 982.56, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 818.45, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 570.72, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 831.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 783.96, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 919.85, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 606.26, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 570.72, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LETERMOVIR 480 MG/24ML IV SOLN", "drug_information": { "unit": "24.000000", "type": "UN" }, "code_information": [ { "code": "00006500401", "type": "NDC" } ], "standard_charges": [ { "minimum": 407.42, "maximum": 1359.01, "gross_charge": 1445.76, "discounted_cash": 795.17, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 838.54, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 789.38, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1156.61, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1224.56, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 420.72, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 693.96, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 866.01, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 864.56, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1359.01, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1272.27, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 407.42, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1228.9, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1084.32, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 509.34, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 983.12, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1359.01, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1132.03, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 789.38, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1149.38, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1084.32, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1272.27, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 838.54, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 789.38, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LETROZOLE 2.5 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "50268047615", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LEUCOVORIN 0.5MG/ML SUSPENSION", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "P8252000038", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LEUCOVORIN 10 MG/ML SYRINGE", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "67457052810", "type": "NDC" } ], "standard_charges": [ { "minimum": 12.76, "maximum": 42.56, "gross_charge": 45.28, "discounted_cash": 24.9, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.26, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.72, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.22, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.35, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.18, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.73, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.12, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.08, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.56, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.85, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.76, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.49, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.96, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.95, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.79, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.56, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.45, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.72, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.96, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.85, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.26, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.72, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LEUCOVORIN CALCIUM 100 MG IJ SOLR", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "67457052810_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 12.76, "maximum": 42.56, "gross_charge": 45.28, "discounted_cash": 24.9, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.26, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.72, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.22, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.35, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.18, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.73, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.12, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.08, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.56, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.85, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.76, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.49, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.96, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.95, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.79, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.56, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.45, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.72, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.96, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.85, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.26, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.72, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LEUCOVORIN CALCIUM 200 MG IJ SOLR", "drug_information": { "unit": "20.000000", "type": "UN" }, "code_information": [ { "code": "71288016230", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LEUCOVORIN CALCIUM 25 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00904670310", "type": "NDC" } ], "standard_charges": [ { "minimum": 6.02, "maximum": 20.09, "gross_charge": 21.37, "discounted_cash": 11.75, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.39, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.67, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.1, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.1, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.22, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.26, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.8, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.09, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.81, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.02, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.16, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.03, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.53, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.53, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.09, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.73, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.67, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.99, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.03, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.81, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.39, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.67, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LEUCOVORIN CALCIUM 5 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00054849619", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", 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"additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 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MG IJ SOLR", "drug_information": { "unit": "0.100000", "type": "UN" }, "code_information": [ { "code": "00143955501", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LEUCOVORIN CALCIUM 500 MG IJ SOLR", "drug_information": { "unit": "50.000000", "type": "UN" }, "code_information": [ { "code": "63323071100", "type": "NDC" } ], "standard_charges": [ { "minimum": 28.71, "maximum": 95.77, "gross_charge": 101.88, "discounted_cash": 56.03, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.09, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.63, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 81.5, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.29, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.65, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 48.9, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.03, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 95.77, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 89.65, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.71, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.6, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 76.41, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.89, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 69.28, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 95.77, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 79.77, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.63, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 80.99, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 76.41, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 89.65, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.09, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.63, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LEUPROLIDE ACETATE (3 MONTH) 11.25 MG IM KIT", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00074366303", "type": "NDC" } ], "standard_charges": [ { "minimum": 883.24, "maximum": 13143.46, "gross_charge": 13982.4, "discounted_cash": 7690.32, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 8109.79, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 883.24, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11185.92, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11843.09, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4068.88, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6711.55, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 8375.46, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 8361.48, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13143.46, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12304.51, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3940.24, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11885.04, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10486.8, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 4926.0, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 9508.03, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 13143.46, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 10948.22, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1192.37, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 11116.01, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10486.8, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12304.51, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8109.79, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 883.24, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "LEUPROLIDE ACETATE (3 MONTH) 22.5 MG IM KIT", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00074334603", "type": "NDC" } ], "standard_charges": [ { "minimum": 96.37, "maximum": 1722.87, "gross_charge": 1832.84, "discounted_cash": 1008.06, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1063.05, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.37, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1466.27, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1552.42, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 533.36, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 879.76, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1097.87, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 1096.04, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1722.87, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1612.9, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 516.49, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1557.91, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1374.63, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 645.71, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1246.33, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1722.87, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1435.11, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 130.11, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1457.11, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1374.63, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1612.9, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1063.05, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.37, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "LEUPROLIDE ACETATE (4 MONTH) 30 MG IM KIT", "drug_information": { "unit": "30.000000", "type": "ME" }, "code_information": [ { "code": "00074368303", "type": "NDC" } ], "standard_charges": [ { "minimum": 96.37, "maximum": 2297.13, "gross_charge": 2443.76, "discounted_cash": 1344.07, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1417.38, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.37, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1955.01, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2069.86, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 711.13, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1173.0, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1463.81, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 1461.37, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2297.13, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2150.51, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 688.65, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2077.2, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1832.82, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 860.94, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1661.76, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2297.13, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1913.46, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 130.11, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1942.79, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1832.82, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2150.51, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1417.38, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.37, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "LEUPROLIDE ACETATE (6 MONTH) 45 MG IM KIT", "drug_information": { "unit": "45.000000", "type": "ME" }, "code_information": [ { "code": "00074347303", "type": "NDC" } ], "standard_charges": [ { "minimum": 96.37, "maximum": 3445.78, "gross_charge": 3665.72, "discounted_cash": 2016.15, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2126.12, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.37, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2932.58, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3104.86, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1066.72, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1759.55, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2195.77, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2192.1, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3445.78, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3225.83, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1033.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3115.86, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2749.29, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1291.43, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2492.69, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3445.78, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2870.26, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 130.11, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2914.25, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2749.29, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3225.83, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2126.12, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.37, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "LEUPROLIDE ACETATE (PED) 11.25 MG IM KIT", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00074228203", "type": "NDC" } ], "standard_charges": [ { "minimum": 883.24, "maximum": 9568.49, "gross_charge": 10179.24, "discounted_cash": 5598.58, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5903.96, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 883.24, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8143.39, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8621.82, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2962.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4886.04, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6097.36, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 6087.19, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9568.49, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8957.73, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2868.51, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8652.35, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7634.43, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3586.15, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6921.88, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 9568.49, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7970.34, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1192.37, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 8092.5, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7634.43, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8957.73, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5903.96, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 883.24, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "LEUPROLIDE ACETATE (PED) 15 MG IM KIT", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00074244003", "type": "NDC" } ], "standard_charges": [ { "minimum": 883.24, "maximum": 10538.73, "gross_charge": 11211.42, "discounted_cash": 6166.28, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 6502.62, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 883.24, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8969.14, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9496.07, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3262.52, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5381.48, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6715.64, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 6704.43, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10538.73, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9866.05, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3159.38, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9529.71, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8408.57, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3949.78, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7623.77, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 10538.73, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8778.54, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1192.37, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 8913.08, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8408.57, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9866.05, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6502.62, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 883.24, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "LEUPROLIDE ACETATE (PED) 7.5 MG IM KIT", "drug_information": { "unit": "7.500000", "type": "ME" }, "code_information": [ { "code": "00074210803", "type": "NDC" } ], "standard_charges": [ { "minimum": 883.24, "maximum": 5270.52, "gross_charge": 5606.94, "discounted_cash": 3083.82, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3252.03, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 883.24, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4485.55, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4749.08, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1631.62, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2691.33, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3358.56, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 3352.95, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5270.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4934.11, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1580.04, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4765.9, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4205.21, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1975.32, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3812.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5270.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4390.23, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1192.37, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4457.52, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4205.21, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4934.11, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3252.03, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 883.24, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "LEUPROLIDE ACETATE (PED)(3MON) 11.25 MG IM KIT", "drug_information": { "unit": "1.500000", "type": "UN" }, "code_information": [ { "code": "00074377903", "type": "NDC" } ], "standard_charges": [ { "minimum": 883.24, "maximum": 29279.52, "gross_charge": 31148.43, "discounted_cash": 17131.64, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 18066.09, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 883.24, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 24918.74, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 26382.72, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9064.19, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14951.25, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 18657.91, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 11394.0, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 29279.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 27410.62, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 8777.63, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 26476.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23361.32, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 10973.59, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 21180.93, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 29279.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24389.22, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1192.37, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 15189.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23361.32, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 27410.62, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 18066.09, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 883.24, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "LEUPROLIDE ACETATE (PED)(3MON) 30 MG IM KIT", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00074969403", "type": "NDC" } ], "standard_charges": [ { "minimum": 883.24, "maximum": 27286.07, "gross_charge": 29027.73, "discounted_cash": 15965.25, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 16836.08, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 883.24, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23222.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 24586.49, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8447.07, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13933.31, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 17387.61, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 11394.0, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 27286.07, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 25544.4, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 8180.01, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 24673.57, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21770.8, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 10226.47, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 19738.86, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27286.07, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 22728.71, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1192.37, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 15189.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21770.8, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 25544.4, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 16836.08, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 883.24, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "LEUPROLIDE ACETATE 1 MG/0.2ML IJ KIT", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00781400332", "type": "NDC" } ], "standard_charges": [ { "minimum": 569.27, "maximum": 1898.91, "gross_charge": 2020.12, "discounted_cash": 1111.07, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1171.67, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1102.99, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", 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"methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1515.09, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 711.69, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1373.68, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1898.91, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", 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"payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1171.67, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1102.99, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LEUPROLIDE ACETATE 3.75 MG IM KIT", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00074364103", "type": "NDC" } ], "standard_charges": [ { "minimum": 883.24, "maximum": 4692.14, "gross_charge": 4991.64, "discounted_cash": 2745.4, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2895.15, "standard_charge_percentage": 58.0, "methodology": 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"additional_payer_notes": "N/A", "standard_charge_dollar": 1406.64, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4242.89, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3743.73, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1758.55, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3394.32, "standard_charge_percentage": 68.0, "methodology": 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"standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4392.64, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2895.15, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 883.24, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "LEUPROLIDE ACETATE 7.5 MG IM KIT", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00074364203", "type": "NDC" } ], "standard_charges": [ { "minimum": 96.37, "maximum": 538.18, "gross_charge": 572.53, "discounted_cash": 314.89, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 332.07, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.37, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 458.02, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 484.93, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 166.61, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 274.81, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 342.95, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 342.37, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 538.18, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": 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"standard_charge_dollar": 455.16, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 429.4, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 503.83, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 332.07, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.37, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "LEVALBUTEROL HCL 0.31 MG/3ML IN NEBU", "drug_information": { "unit": "3.000000", "type": "UN" }, "code_information": [ { "code": "76204070001", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": 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"standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LEVALBUTEROL HCL 0.63 MG/3ML IN NEBU", "drug_information": { "unit": "3.000000", "type": "UN" }, "code_information": [ { "code": "76204080001", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LEVALBUTEROL HCL 1.25 MG/0.5ML IN NEBU", "drug_information": { "unit": "0.500000", "type": "UN" }, "code_information": [ { "code": "00378699393", "type": "NDC" } ], "standard_charges": [ { "minimum": 3.42, "maximum": 11.41, "gross_charge": 12.14, "discounted_cash": 6.68, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.63, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.71, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.28, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.53, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.83, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.27, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.26, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.41, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.68, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.42, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.32, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.11, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.28, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.26, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.41, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.51, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.63, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.65, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.11, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.68, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.63, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LEVALBUTEROL HCL 1.25 MG/3ML IN NEBU", "drug_information": { "unit": "3.000000", "type": "UN" }, "code_information": [ { "code": "00115993278", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LEVETIRACETAM 100 MG/ML IV SYRINGE", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "00409188602", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LEVETIRACETAM 100 MG/ML PO SOLN", "drug_information": { "unit": "473.000000", "type": "UN" }, "code_information": [ { "code": "00121479940", "type": "NDC" }, { "code": "31722057447", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.54, "maximum": 5.13, "gross_charge": 5.46, "discounted_cash": 3.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.17, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.98, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.62, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.59, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.62, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.27, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.27, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.13, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.54, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.1, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.71, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.13, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.28, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.98, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.34, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.1, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.17, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.98, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" }, { "minimum": 9.07, "maximum": 30.27, "gross_charge": 32.2, "discounted_cash": 17.71, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.68, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.58, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.76, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.27, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.37, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.46, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.29, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.26, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.27, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.34, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.07, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.37, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.15, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.34, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.9, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.27, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.21, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.58, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.6, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.15, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.34, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.68, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.58, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LEVETIRACETAM 1000 MG/100ML RTU", "drug_information": { "unit": "100.000000", "type": "UN" }, "code_information": [ { "code": "00264100990", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LEVETIRACETAM 250 MG PO TABS", "drug_information": { "unit": "2.000000", "type": "UN" }, "code_information": [ { "code": "68084085901", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LEVETIRACETAM 500 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687065701", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LEVETIRACETAM 500 MG/100ML RTU", "drug_information": { "unit": "100.000000", "type": "UN" }, "code_information": [ { "code": "00264500990", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LEVETIRACETAM 500 MG/5ML IV SOLN", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "00409188602_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LEVETIRACETAM ER 500 MG PO TB24", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60505328006", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LEVETIRACETAM ER 750 MG PO TB24", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "43547034606", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LEVOBUNOLOL HCL 0.5 % OP SOLN", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "24208050505", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LEVOCARNITINE 1 GM/10ML PO SOLN", "drug_information": { "unit": "118.000000", "type": "UN" }, "code_information": [ { "code": "70954014010", "type": "NDC" } ], "standard_charges": [ { "minimum": 19.02, "maximum": 63.45, "gross_charge": 67.5, "discounted_cash": 37.13, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.15, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.86, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 57.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.4, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.43, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.37, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.45, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.4, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.02, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 57.38, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.63, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.78, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.9, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.45, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.85, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.86, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 53.66, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.63, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.4, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.15, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.86, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LEVOCARNITINE 200 MG/ML CONTINUOUS INFUSION SYRINGE", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "54482014701", "type": "NDC" } ], "standard_charges": [ { "minimum": 24.22, "maximum": 1158.0, "gross_charge": 85.93, "discounted_cash": 47.26, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.84, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.92, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.59, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.25, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 51.47, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 51.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 80.77, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.62, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.22, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 73.04, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 64.45, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.27, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 58.43, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 80.77, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 67.28, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.92, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 68.31, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 64.45, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.62, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.84, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.92, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LEVOCARNITINE 200 MG/ML IV SOLN", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "54482014701_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 24.22, "maximum": 1158.0, "gross_charge": 85.93, "discounted_cash": 47.26, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.84, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.92, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.59, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.25, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 51.47, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 51.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 80.77, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.62, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.22, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 73.04, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 64.45, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.27, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 58.43, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 80.77, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 67.28, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.92, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 68.31, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 64.45, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.62, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.84, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.92, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LEVOCARNITINE 330 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "54482014407", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LEVOCARNITINE SYRINGE", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "54482014701_3", "type": "NDC" } ], "standard_charges": [ { "minimum": 24.22, "maximum": 1158.0, "gross_charge": 85.93, "discounted_cash": 47.26, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.84, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.92, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.59, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.25, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 51.47, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 51.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 80.77, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.62, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.22, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 73.04, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 64.45, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.27, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 58.43, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 80.77, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 67.28, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.92, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 68.31, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 64.45, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.62, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.84, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.92, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LEVOFLOXACIN 25 MG/ML PO SOLN", "drug_information": { "unit": "480.000000", "type": "UN" }, "code_information": [ { "code": "00527194870", "type": "NDC" } ], "standard_charges": [ { "minimum": 499.6, "maximum": 1666.53, "gross_charge": 1772.9, "discounted_cash": 975.1, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1028.28, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 968.0, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1418.32, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1501.65, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 515.91, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 850.99, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1061.97, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 1060.19, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1666.53, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1560.15, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 499.6, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1506.97, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1329.68, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 624.59, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1205.57, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1666.53, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1388.18, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 968.0, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1409.46, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1329.68, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1560.15, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1028.28, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 968.0, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LEVOFLOXACIN 250 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00904635161", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LEVOFLOXACIN 250 MG/50 ML RTU", "drug_information": { "unit": "50.000000", "type": "UN" }, "code_information": [ { "code": "00143972224", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LEVOFLOXACIN 5 MG/ML IVPB FROM RTU", "drug_information": { "unit": "100.000000", "type": "UN" }, "code_information": [ { "code": "25021013282", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LEVOFLOXACIN 5 MG/ML SYRINGE FROM RTU (PEDS)", "drug_information": { "unit": "100.000000", "type": "UN" }, "code_information": [ { "code": "25021013282_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LEVOFLOXACIN 500 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00904635261", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LEVOFLOXACIN 500 MG/100 ML RTU", "drug_information": { "unit": "100.000000", "type": "UN" }, "code_information": [ { "code": "25021013282_3", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LEVOFLOXACIN 750 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00904635361", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LEVOFLOXACIN 750 MG/150 ML RTU", "drug_information": { "unit": "150.000000", "type": "UN" }, "code_information": [ { "code": "00143972024", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": 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"additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LEVONORGEST-ETH ESTRAD 91-DAY 0.1-0.02 & 0.01 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00378728490", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LEVONORGEST-ETH ESTRAD 91-DAY 0.15-0.03 &0.01 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68180084613", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LEVONORGEST-ETH ESTRAD 91-DAY 0.15-0.03 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68462067295", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LEVONORGESTREL 1.5 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68180085211", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.97, "maximum": 6.58, "gross_charge": 7.0, "discounted_cash": 3.85, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.06, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.82, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.6, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.93, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.04, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.36, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.19, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.19, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.58, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.16, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.97, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.95, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.25, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.47, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.76, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.58, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.48, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.82, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.57, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.25, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.16, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.06, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.82, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LEVONORGESTREL 13.5 MG IU IUD", "drug_information": { "unit": "13.500000", "type": "ME" }, "code_information": [ { "code": "50419042201", "type": "NDC" } ], "standard_charges": [ { "minimum": 402.73, "maximum": 1343.37, "gross_charge": 1429.12, "discounted_cash": 786.02, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 828.89, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 780.3, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1143.3, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1210.46, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 415.87, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 685.98, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 856.04, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 854.61, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1343.37, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1257.63, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 402.73, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1214.75, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1071.84, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 503.48, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 971.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1343.37, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1119.0, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 780.3, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1136.15, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1071.84, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1257.63, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 828.89, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 780.3, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LEVONORGESTREL 19.5 MG IU IUD", "drug_information": { "unit": "19.500000", "type": "ME" }, "code_information": [ { "code": "50419042401", "type": "NDC" } ], "standard_charges": [ { "minimum": 432.61, "maximum": 1443.07, "gross_charge": 1535.18, "discounted_cash": 844.35, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 890.4, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 838.21, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1228.14, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1300.3, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 446.74, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 736.89, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 919.57, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 918.04, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1443.07, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1350.96, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 432.61, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1304.9, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1151.39, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 540.84, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1043.92, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1443.07, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1202.05, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 838.21, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", 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total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LEVONORGESTREL 20 MCG/DAY IU IUD", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "50419042301", "type": "NDC" } ], "standard_charges": [ { "minimum": 620.92, "maximum": 2071.2, "gross_charge": 2203.4, "discounted_cash": 1211.87, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1277.97, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1203.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1762.72, 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"methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1063.06, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 1061.28, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1668.24, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1561.75, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 500.12, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1508.51, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1331.04, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 625.23, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1206.81, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { 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"methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1561.75, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1029.34, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 969.0, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LEVONORGESTREL-ETHINYL ESTRAD 0.1-20 MG-MCG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "70700011885", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, 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"additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { 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charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LEVOTHYROXINE SODIUM 100 MCG FT TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687049701", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LEVOTHYROXINE SODIUM 100 MCG IV SOLR", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "63323064907", "type": "NDC" } ], "standard_charges": [ { "minimum": 64.38, "maximum": 214.74, "gross_charge": 228.45, "discounted_cash": 125.65, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 132.5, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 124.73, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 182.76, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 193.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 66.48, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 109.66, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 136.84, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 136.61, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 214.74, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 201.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 64.38, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 194.18, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 171.34, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 80.48, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 155.35, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 214.74, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 178.88, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 124.73, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 181.62, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 171.34, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 201.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 132.5, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 124.73, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LEVOTHYROXINE SODIUM 100 MCG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687049701_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LEVOTHYROXINE SODIUM 100 MCG/5ML IV SOLN", "drug_information": { "unit": "1.250000", "type": "UN" }, "code_information": [ { "code": "63323088510", "type": "NDC" } ], "standard_charges": [ { "minimum": 54.64, "maximum": 182.26, "gross_charge": 193.89, "discounted_cash": 106.64, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 112.46, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 105.86, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 155.11, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 164.22, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 56.42, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.07, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 116.14, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 115.95, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 182.26, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 170.62, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.64, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 164.81, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 145.42, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 68.31, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 131.85, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 182.26, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 151.82, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 105.86, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 154.14, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 145.42, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 170.62, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 112.46, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 105.86, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LEVOTHYROXINE SODIUM 112 MCG FT TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687050801", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All 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}, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, 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}, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", 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"PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LEVOTHYROXINE SODIUM 125 MCG FT TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687051901", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": 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total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LEVOTHYROXINE SODIUM 125 MCG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687051901_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LEVOTHYROXINE SODIUM 137 MCG FT TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687056301", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All 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}, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LEVOTHYROXINE SODIUM 137 MCG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687056301_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", 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}, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", 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"PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LEVOTHYROXINE SODIUM 150 MCG FT TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687053001", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": 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total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LEVOTHYROXINE SODIUM 150 MCG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687053001_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LEVOTHYROXINE SODIUM 175 MCG FT TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "42292004020", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LEVOTHYROXINE SODIUM 175 MCG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "42292004020_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", 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"PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LEVOTHYROXINE SODIUM 200 MCG FT TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00074714811", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of 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"methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": 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total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LEVOTHYROXINE SODIUM 200 MCG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00074714811_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LEVOTHYROXINE SODIUM 25 MCG FT TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "51079044420", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LEVOTHYROXINE SODIUM 25 MCG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687045301", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", 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} ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of 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"methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": 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total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LEVOTHYROXINE SODIUM 300 MCG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00074714990_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LEVOTHYROXINE SODIUM 50 MCG FT TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687046401", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LEVOTHYROXINE SODIUM 50 MCG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687046401_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", 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}, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", 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} ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of 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"additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": 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total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LEVOTHYROXINE SODIUM 75 MCG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687047501_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LEVOTHYROXINE SODIUM 88 MCG FT TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "42292003820", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LEVOTHYROXINE SODIUM 88 MCG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "42292003820_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", 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}, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", 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"type": "NDC" } ], "standard_charges": [ { "minimum": 2.0, "maximum": 6.66, "gross_charge": 7.08, "discounted_cash": 3.89, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.11, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.87, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.66, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.06, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.24, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.23, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.66, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.23, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.02, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.31, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.49, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.81, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.66, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.54, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.87, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.63, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.31, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.23, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.11, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.87, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LIDO-EPINEPHRINE-TETRACAINE 4-0.18-0.5 % EX GEL", "drug_information": { "unit": "3.000000", "type": "UN" }, "code_information": [ { "code": "71266629001", "type": "NDC" } ], "standard_charges": [ { "minimum": 6.4, "maximum": 21.34, "gross_charge": 22.7, "discounted_cash": 12.49, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.17, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.39, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.16, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.23, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.61, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.9, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.6, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.57, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.34, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.98, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.4, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.3, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.03, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.0, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.44, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.34, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.77, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.39, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.05, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.03, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.98, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.17, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.39, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LIDO-EPINEPHRINE-TETRACAINE EX GEL (MULTI-GPI)", "drug_information": { "unit": "3.000000", "type": "UN" }, "code_information": [ { "code": "71266629001_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 6.4, "maximum": 21.34, "gross_charge": 22.7, "discounted_cash": 12.49, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.17, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { 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"methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.6, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.57, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.34, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.98, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.4, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.3, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.03, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.0, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.44, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.34, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.77, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.39, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.05, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.03, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.98, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.17, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.39, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LIDOCAINE (ANORECTAL) 5 % EX CREA", "drug_information": { "unit": "15.000000", "type": "GR" }, "code_information": [ { "code": "24357070215", "type": "NDC" } ], "standard_charges": [ { "minimum": 8.93, "maximum": 29.8, "gross_charge": 31.7, "discounted_cash": 17.44, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.39, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.31, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.36, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.85, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.22, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.22, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.99, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.9, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.93, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.95, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.78, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.17, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.56, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.82, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.31, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.78, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.9, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.39, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.31, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LIDOCAINE 2 % EX GEL UROJET", "drug_information": { "unit": "6.000000", "type": "UN" }, "code_information": [ { "code": "25021067376", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.32, "maximum": 7.73, "gross_charge": 8.22, "discounted_cash": 4.52, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.77, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.49, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.58, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.96, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.95, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.73, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.23, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.99, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.17, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.9, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.59, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.73, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.44, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.49, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.53, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.17, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.23, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.77, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.49, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LIDOCAINE 2 % PF 20 MG/ML 10 ML (BULK CHARGE)", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "63323049697", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 1158.0, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.72, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LIDOCAINE 4 % EX CREA", "drug_information": { "unit": "5.000000", "type": "GR" }, "code_information": [ { "code": "24357070106", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.79, "maximum": 5.96, "gross_charge": 6.34, "discounted_cash": 3.49, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.68, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.46, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.07, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.37, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.84, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.04, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.8, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.79, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.96, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.58, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.79, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.76, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.23, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.31, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.96, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.96, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.46, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.04, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.76, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.58, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.68, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.46, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LIDOCAINE 5 % EX OINT", "drug_information": { "unit": "50.000000", "type": "GR" }, "code_information": [ { "code": "51672300805", "type": "NDC" } ], "standard_charges": [ { "minimum": 8.94, "maximum": 29.83, "gross_charge": 31.73, "discounted_cash": 17.45, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.4, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.32, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.38, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.23, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.23, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.01, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.97, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.83, "standard_charge_percentage": 94.0, "methodology": "percent of total 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"standard_charge_dollar": 11.18, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.58, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.83, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.84, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.32, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.23, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.8, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.92, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.4, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.32, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LIDOCAINE 5 % EX PTCH", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00591352530", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": 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billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LIDOCAINE HCL (CARDIAC) 100 MG/5ML IV SOSY", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "76329339001", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 1158.0, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.72, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LIDOCAINE HCL (PF) 0.5 % IJ SOLN", "drug_information": { "unit": "50.000000", "type": "UN" }, "code_information": [ { "code": "00409427801", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 1158.0, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.72, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LIDOCAINE HCL (PF) 1 % IJ SOLN", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "63323049257", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 1158.0, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.72, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 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"additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LIDOCAINE HCL (PF) 1 % IJ SOLN (APHERESIS)", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "63323049257_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 1158.0, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 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"standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.72, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", 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"plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LIDOCAINE HCL (PF) 1 % IJ SOLN FOR NEEDLE-FREE INJECTOR", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "63323049257_4", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 1158.0, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.72, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LIDOCAINE HCL (PF) 1 % IJ SOLN NEBULIZED", "drug_information": { "unit": "20.000000", "type": "ME" }, "code_information": [ { "code": "55150016102", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 1158.0, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.72, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LIDOCAINE HCL (PF) 1% IJ SOLN 2ML (BULK CHARGE)", "drug_information": { "unit": "2.000000", "type": "UN" }, "code_information": [ { "code": "63323049227", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 1158.0, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.72, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LIDOCAINE HCL (PF) 1.5 % IJ SOLN", "drug_information": { "unit": "20.000000", "type": "UN" }, "code_information": [ { "code": "63323049391", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 1158.0, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.72, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LIDOCAINE HCL (PF) 2 % IJ SOLN", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "63323049507", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 1158.0, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.72, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LIDOCAINE HCL (PF) 2% IJ SOLN 5ML (BULK CHARGE)", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "63323049507_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 1158.0, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.72, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LIDOCAINE HCL (PF) 4 % IJ SOLN", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "00409428301", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 1158.0, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": 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Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, 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"standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LIDOCAINE HCL 0.5 % IJ SOLN", "drug_information": { "unit": "50.000000", "type": "UN" }, "code_information": [ { "code": "00409427501", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 1158.0, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.72, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", 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total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", 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"additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LIDOCAINE HCL 1 % IJ SOLN", "drug_information": { "unit": "20.000000", "type": "UN" }, "code_information": [ { "code": "00409427601", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 1158.0, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.72, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LIDOCAINE HCL 1 % IJ SOLN 50 ML VIAL (BULK CHARGE)", "drug_information": { "unit": "50.000000", "type": "UN" }, "code_information": [ { "code": "00409427602", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 1158.0, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.72, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total 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"standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LIDOCAINE HCL 1% (PF) IN 0.9% SODIUM CHLORIDE 10ML", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "61553033865", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 1158.0, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.72, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { 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Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.72, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": 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"plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.95, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.48, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.96, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.6, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.99, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.58, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.21, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.19, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.88, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.06, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.86, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.65, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.28, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.83, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": 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"percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.28, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.06, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.95, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.48, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LIDOCAINE HCL 2 % IJ SOLN", "drug_information": { "unit": "20.000000", "type": "UN" }, "code_information": [ { "code": "55150025520", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 1158.0, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.72, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LIDOCAINE HCL 2 % IJ SOLN 20 ML VIAL (BULK CHARGE)", "drug_information": { "unit": "20.000000", "type": "UN" }, "code_information": [ { "code": "63323048627", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 1158.0, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.72, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LIDOCAINE HCL 2 % IJ SOLN 50 ML VIAL (BULK CHARGE)", "drug_information": { "unit": "50.000000", "type": "UN" }, "code_information": [ { "code": "00143957510", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 1158.0, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.72, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LIDOCAINE HCL 2% EX GEL 20ML UROJET (BULK CHARGE)", "drug_information": { "unit": "20.000000", "type": "UN" }, "code_information": [ { "code": "76329301505", "type": "NDC" } ], "standard_charges": [ { "minimum": 5.58, "maximum": 18.6, "gross_charge": 19.79, "discounted_cash": 10.88, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.48, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.81, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.83, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.76, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.76, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.5, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.85, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.83, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.42, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.58, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.82, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.84, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.97, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.46, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.5, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.81, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.73, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.84, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.42, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.48, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.81, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LIDOCAINE HCL 3 % EX CREA", "drug_information": { "unit": "28.300000", "type": "GR" }, "code_information": [ { "code": "59088099703", "type": "NDC" } ], "standard_charges": [ { "minimum": 12.7, "maximum": 42.38, "gross_charge": 45.08, "discounted_cash": 24.79, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.15, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.61, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.06, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.18, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.12, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.64, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.0, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.38, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.67, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.7, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.32, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.81, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.88, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.65, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.38, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.3, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.61, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.84, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.81, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.67, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.15, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.61, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LIDOCAINE HCL 3.5 % OP GEL", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "82584079225", "type": "NDC" } ], "standard_charges": [ { "minimum": 12.88, "maximum": 42.98, "gross_charge": 45.72, "discounted_cash": 25.15, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.52, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.96, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.58, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.72, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.3, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.95, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.34, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.98, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.23, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.88, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.86, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.29, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.11, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.09, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.98, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.8, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.96, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.35, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.29, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.23, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.52, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.96, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LIDOCAINE HCL 4 % EX SOLN", "drug_information": { "unit": "50.000000", "type": "UN" }, "code_information": [ { "code": "70954051810", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.71, "maximum": 39.06, "gross_charge": 41.55, "discounted_cash": 22.85, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.1, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.69, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.24, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.19, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.09, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.94, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.85, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.06, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.56, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.71, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.32, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.16, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.64, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.25, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.06, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.53, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.69, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.03, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.16, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.56, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.1, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.69, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LIDOCAINE HCL 4 % MT SOLN", "drug_information": { "unit": "4.000000", "type": "UN" }, "code_information": [ { "code": "76329630005", "type": "NDC" } ], "standard_charges": [ { "minimum": 18.11, "maximum": 60.4, "gross_charge": 64.26, "discounted_cash": 35.34, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.27, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.09, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 51.41, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.43, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": 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"additional_payer_notes": "N/A", "standard_charge_dollar": 56.55, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.11, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.62, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 48.2, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.64, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.7, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.09, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 51.09, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 48.2, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 56.55, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.27, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.09, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LIDOCAINE HCL(CARDIAC)20 MG/ML -CODE USE PEDS", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "00409132305", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 1158.0, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.72, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LIDOCAINE IN D5W 8-5 MG/ML-% IV SOLN", "drug_information": { "unit": "250.000000", "type": "UN" }, "code_information": [ { "code": "00338041102_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LIDOCAINE IN D5W 8-5 MG/ML-% IV SOLN|DISCARDED DRUG NOT ADMINISTERED", "drug_information": { "unit": "250.000000", "type": "UN" }, "code_information": [ { "code": "00338041102", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.97, "maximum": 3.22, "gross_charge": 3.43, "discounted_cash": 1.89, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.99, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.87, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.74, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.91, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.0, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.65, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.05, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.05, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.22, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.02, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.97, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.92, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.57, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.21, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.33, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.22, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.69, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.87, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.73, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.57, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.02, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.99, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.87, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LIDOCAINE VISCOUS HCL 2 % MT SOLN", "drug_information": { "unit": "15.000000", "type": "UN" }, "code_information": [ { "code": "00121495040", "type": "NDC" } ], "standard_charges": [ { "minimum": 3.07, "maximum": 10.26, "gross_charge": 10.91, "discounted_cash": 6.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.33, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.96, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.73, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.24, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.17, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.24, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.54, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.52, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.26, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.07, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.27, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.18, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.84, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.42, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.26, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.54, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.96, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.67, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.18, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.33, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.96, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LIDOCAINE-EPINEPHRINE (PF) 1 %-1:200000 IJ SOLN", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "63323048737", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 1158.0, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.72, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LIDOCAINE-EPINEPHRINE (PF) 1.5 %-1:200000 IJ SOLN", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "63323048837", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 1158.0, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.72, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, 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Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, 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charges" } ], "additional_generic_notes": "" } ] }, { "description": "LIDOCAINE-EPINEPHRINE 1 %-1:100000 IJ SOLN", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "63323048227", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 1158.0, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, 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"standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", 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"methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LIDOCAINE-EPINEPHRINE 1% 20ML (BULK CHARGE)", "drug_information": { "unit": "20.000000", "type": "UN" }, "code_information": [ { "code": "63323048227_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 1158.0, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 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"plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LIDOCAINE-EPINEPHRINE 1% 30ML (BULK CHARGE)", "drug_information": { "unit": "30.000000", "type": "UN" }, "code_information": [ { "code": "00409317802", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 1158.0, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.72, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LIDOCAINE-EPINEPHRINE 2 %-1:100000 IJ SOLN", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00409318201", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 1158.0, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.72, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LIDOCAINE-EPINEPHRINE 2%-1:200000 20 ML (BULK CHARGE)", "drug_information": { "unit": "20.000000", "type": "UN" }, "code_information": [ { "code": "00409318301_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 1158.0, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.72, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LIDOCAINE-HYDROCORT (PERIANAL) 3-0.5 % EX CREA", "drug_information": { "unit": "28.350000", "type": "GR" }, "code_information": [ { "code": "13925016001", "type": "NDC" } ], "standard_charges": [ { "minimum": 12.24, "maximum": 40.84, "gross_charge": 43.45, "discounted_cash": 23.9, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.72, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.76, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.8, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.86, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.03, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.98, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.84, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.24, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.24, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.93, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.59, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.31, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.55, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.84, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.02, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.72, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.54, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.59, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.24, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.72, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Ligate/strip long leg vein", "code_information": [ { "code": "37722", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2320.02, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1718.54, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 11988.82, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 21753.9, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2320.02, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 21753.9, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Ligation nasal sinus artery", "code_information": [ { "code": "30915", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2320.02, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1718.54, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 28465.78, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 52071.03, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2320.02, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 52071.03, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Ligation of a-v fistula", "code_information": [ { "code": "37607", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2320.02, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1718.54, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 18383.65, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 33357.44, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2320.02, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 33357.44, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Ligation of extremity artery", "code_information": [ { "code": "37618", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 13154.15, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 24147.41, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 24147.41, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Ligation of hemorrhoid(s)", "code_information": [ { "code": "46221", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 672.02, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 497.79, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 2345.2, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 4255.4, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 672.02, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 4255.4, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Ligation of neck artery", "code_information": [ { "code": "37605", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2320.02, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1718.54, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 17268.66, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 31334.3, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2320.02, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 31334.3, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Ligation upper jaw artery", "code_information": [ { "code": "30920", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2320.02, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1718.54, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 20169.64, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 36598.15, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2320.02, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 36598.15, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LINACLOTIDE 145 MCG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00456120130", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.5, "maximum": 38.36, "gross_charge": 40.81, "discounted_cash": 22.45, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.67, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.28, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.65, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.57, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.88, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.59, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.45, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.36, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.91, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.5, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.69, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.61, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.38, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.75, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.36, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.95, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.28, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.44, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.61, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.91, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.67, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.28, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LINACLOTIDE 290 MCG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00456120230", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.5, "maximum": 38.36, "gross_charge": 40.81, "discounted_cash": 22.45, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.67, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.28, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.65, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.57, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.88, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.59, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.45, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.36, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.91, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.5, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.69, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.61, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.38, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.75, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.36, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.95, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.28, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.44, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.61, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.91, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.67, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.28, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LINACLOTIDE 72 MCG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00456120330", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.5, "maximum": 38.36, "gross_charge": 40.81, "discounted_cash": 22.45, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.67, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.28, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.65, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.57, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.88, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.59, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.45, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.36, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.91, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.5, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.69, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.61, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.38, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.75, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.36, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.95, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.28, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.44, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.61, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.91, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.67, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.28, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LINAGLIPTIN 5 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00597014030", "type": "NDC" } ], "standard_charges": [ { "minimum": 8.71, "maximum": 29.06, "gross_charge": 30.91, "discounted_cash": 17.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.93, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.88, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.73, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.18, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.99, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.84, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.52, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.48, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.06, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.71, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.27, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.18, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.89, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.02, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.06, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.2, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.88, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.57, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.18, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.93, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.88, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LINEZOLID 100 MG/5ML PO SUSR", "drug_information": { "unit": "150.000000", "type": "UN" }, "code_information": [ { "code": "60687075405", "type": "NDC" } ], "standard_charges": [ { "minimum": 111.85, "maximum": 373.11, "gross_charge": 396.93, "discounted_cash": 218.31, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 230.22, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 216.72, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 317.54, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 336.2, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 115.51, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 190.53, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 237.76, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 237.36, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 373.11, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 349.3, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 111.85, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 337.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 297.7, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 139.84, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 269.91, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 373.11, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 310.8, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 216.72, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 315.56, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 297.7, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 349.3, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 230.22, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 216.72, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LINEZOLID 2 MG/ML IN DEXTROSE 5% IT INJ", "drug_information": { "unit": "300.000000", "type": "UN" }, "code_information": [ { "code": "00143953410_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LINEZOLID 2 MG/ML IVPB FROM RTU (PED)", "drug_information": { "unit": "300.000000", "type": "UN" }, "code_information": [ { "code": "00143953410_3", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LINEZOLID 2 MG/ML SYRINGE FROM RTU (PED)", "drug_information": { "unit": "300.000000", "type": "UN" }, "code_information": [ { "code": "00143953410_4", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LINEZOLID 600 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "67877041984", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LINEZOLID 600 MG/300ML IV SOLN", "drug_information": { "unit": "300.000000", "type": "UN" }, "code_information": [ { "code": "00143953410", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LIOTHYRONINE SODIUM 10 MCG/ML IV SOLN", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "39822015101", "type": "NDC" } ], "standard_charges": [ { "minimum": 352.22, "maximum": 1174.89, "gross_charge": 1249.88, "discounted_cash": 687.43, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 724.93, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 682.43, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1084.9, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 363.72, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 599.94, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 748.68, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 747.43, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1174.89, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1099.89, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 352.22, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1062.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 937.41, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 440.33, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 849.92, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1174.89, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 978.66, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 682.43, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 993.65, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 937.41, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1099.89, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 724.93, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 682.43, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LIOTHYRONINE SODIUM 25 MCG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "1671416701", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LIOTHYRONINE SODIUM 5 MCG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "1671416601", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LIQUIBAND SKIN ADHESIVE", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "08252000089", "type": "NDC" } ], "standard_charges": [ { "minimum": 10.13, "maximum": 1158.0, "gross_charge": 35.93, "discounted_cash": 19.76, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.84, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.62, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.19, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.46, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.25, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.52, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.49, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.77, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.62, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.54, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.95, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.66, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.43, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.77, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.62, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.56, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.95, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.62, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.84, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.62, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LIRAGLUTIDE 18 MG/3ML SC SOPN", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00169406012", "type": "NDC" } ], "standard_charges": [ { "minimum": 242.76, "maximum": 809.77, "gross_charge": 861.46, "discounted_cash": 473.8, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 499.65, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 470.36, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 689.17, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 729.66, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 250.68, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 413.5, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 516.01, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 515.15, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 809.77, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 758.08, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 242.76, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 732.24, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 646.1, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 303.49, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 585.79, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 809.77, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 674.52, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 470.36, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 684.86, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 646.1, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 758.08, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 499.65, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 470.36, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LISDEXAMFETAMINE DIMESYLATE 20 MG PO CAPS", "drug_information": { "unit": "2.000000", "type": "UN" }, "code_information": [ { "code": "3172235101", "type": "NDC" } ], "standard_charges": [ { "minimum": 3.14, "maximum": 10.49, "gross_charge": 11.16, "discounted_cash": 6.14, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.47, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.09, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.93, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.45, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.25, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.36, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.68, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.67, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.49, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.82, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.14, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.49, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.37, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.93, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.59, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.49, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.74, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.09, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.87, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.37, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.82, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.47, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.09, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LISDEXAMFETAMINE DIMESYLATE 30 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "R0406511301", "type": "NDC" } ], "standard_charges": [ { "minimum": 7.84, "maximum": 26.16, "gross_charge": 27.83, "discounted_cash": 15.31, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.14, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.2, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.26, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.57, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.1, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.36, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.67, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.64, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.16, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.49, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.84, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.66, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.87, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.8, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.92, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.16, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.79, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.2, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.12, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.87, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.49, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.14, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.2, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LISINOPRIL 1 MG/ML PO SOLN", "drug_information": { "unit": "150.000000", "type": "UN" }, "code_information": [ { "code": "52652300101", "type": "NDC" } ], "standard_charges": [ { "minimum": 399.66, "maximum": 1333.14, "gross_charge": 1418.23, "discounted_cash": 780.03, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 822.57, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 774.35, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1134.58, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1201.24, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 412.7, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 680.75, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 849.52, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 848.1, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1333.14, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1248.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 399.66, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1205.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1063.67, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 499.64, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 964.4, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1333.14, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1110.47, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 774.35, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1127.49, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1063.67, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1248.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 822.57, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 774.35, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LISINOPRIL 10 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687032501", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LISINOPRIL 2.5 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687065621", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LISINOPRIL 20 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687033301", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LISINOPRIL 40 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687067801", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LISINOPRIL 5 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00904679761", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LITHIUM CARBONATE 150 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00054852625", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LITHIUM CARBONATE 300 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00054852725", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LITHIUM CARBONATE ER 300 MG PO TBCR", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68084064001", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LITHIUM CARBONATE ER 450 MG PO TBCR", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68084065501", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LOMUSTINE 10 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "58181304005", "type": "NDC" } ], "standard_charges": [ { "minimum": 107.62, "maximum": 359.0, "gross_charge": 381.91, "discounted_cash": 210.05, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 221.51, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 208.52, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 305.53, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 323.48, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 111.14, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 183.32, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 228.76, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 228.38, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 359.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 336.08, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 107.62, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 324.62, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 286.43, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 134.55, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 259.7, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 359.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 299.04, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 208.52, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 303.62, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 286.43, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 336.08, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 221.51, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 208.52, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LOMUSTINE 100 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "58181304205", "type": "NDC" } ], "standard_charges": [ { "minimum": 1358.08, "maximum": 4530.15, "gross_charge": 4819.31, "discounted_cash": 2650.62, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2795.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2631.34, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3855.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4081.96, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1402.42, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2313.27, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2886.77, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2881.95, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4530.15, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4240.99, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1358.08, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4096.41, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3614.48, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1697.84, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3277.13, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4530.15, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3773.52, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2631.34, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3831.35, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3614.48, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4240.99, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2795.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2631.34, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LOMUSTINE 40 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "58181304105", "type": "NDC" } ], "standard_charges": [ { "minimum": 491.97, "maximum": 1641.06, "gross_charge": 1745.81, "discounted_cash": 960.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1012.57, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 953.21, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1396.65, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1478.7, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 508.03, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 837.99, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1045.74, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 1043.99, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1641.06, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1536.31, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 491.97, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1483.94, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1309.36, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 615.05, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1187.15, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1641.06, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1366.97, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 953.21, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1387.92, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1309.36, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1536.31, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1012.57, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 953.21, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LONCASTUXIMAB TESIRINE-LPYL 10 MG IV SOLR", "drug_information": { "unit": "2.000000", "type": "UN" }, "code_information": [ { "code": "79952011001", "type": "NDC" } ], "standard_charges": [ { "minimum": 11394.0, "maximum": 66270.0, "gross_charge": 70500.0, "discounted_cash": 38775.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 40890.0, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 38493.0, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 56400.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 59713.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20515.5, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33840.0, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 42229.5, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 11394.0, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 66270.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 62040.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 19866.9, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 59925.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52875.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 24837.15, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 47940.0, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 66270.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 55201.5, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38493.0, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 15189.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52875.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 62040.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 40890.0, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38493.0, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LONCASTUXIMAB TESIRINE-LPYL 10 MG IV SOLR|DISCARDED DRUG NOT ADMINISTERED", "drug_information": { "unit": "2.000000", "type": "UN" }, "code_information": [ { "code": "79952011001_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 11394.0, "maximum": 66270.0, "gross_charge": 70500.0, "discounted_cash": 38775.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 40890.0, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 38493.0, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 56400.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 59713.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20515.5, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33840.0, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 42229.5, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 11394.0, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 66270.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 62040.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 19866.9, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 59925.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52875.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 24837.15, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 47940.0, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 66270.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 55201.5, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38493.0, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 15189.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52875.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 62040.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 40890.0, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38493.0, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LOPERAMIDE HCL 2 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687022901", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LOPINAVIR-RITONAVIR 400-100 MG/5ML PO SOLN", "drug_information": { "unit": "160.000000", "type": "UN" }, "code_information": [ { "code": "00074395646", "type": "NDC" } ], "standard_charges": [ { "minimum": 326.73, "maximum": 1089.88, "gross_charge": 1159.45, "discounted_cash": 637.7, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 672.48, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 633.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 927.56, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 982.05, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 337.4, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 556.54, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 694.51, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 693.35, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1089.88, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1020.32, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 326.73, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 985.53, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 869.59, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 408.47, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 788.43, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1089.88, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 907.85, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 633.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 921.76, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 869.59, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1020.32, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 672.48, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 633.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LORATADINE 10 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00904685261", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LORATADINE 10 MG PO TBDP", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "11523715702", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LORATADINE 5 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "R4580265065", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LORATADINE 5 MG/5ML PO SOLN", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "51672207308", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LORAZEPAM 0.5 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00904600761", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.25, "maximum": 7.52, "gross_charge": 8.0, "discounted_cash": 4.4, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.4, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.78, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.33, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.84, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.79, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.25, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.8, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.82, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.44, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.26, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.36, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LORAZEPAM 1 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "1310708401", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.25, "maximum": 7.52, "gross_charge": 8.0, "discounted_cash": 4.4, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.4, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.78, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.33, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.84, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.79, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.25, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.8, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.82, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.44, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.26, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.36, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LORAZEPAM 2 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "1310708501", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.25, "maximum": 7.52, "gross_charge": 8.0, "discounted_cash": 4.4, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.4, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.78, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.33, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.84, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.79, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.25, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.8, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.82, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.44, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.26, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.36, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LORAZEPAM 2 MG/ML IJ SOLN", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00641604425", "type": "NDC" } ], "standard_charges": [ { "minimum": 12.68, "maximum": 42.3, "gross_charge": 45.0, "discounted_cash": 24.75, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.1, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.12, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.1, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.91, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.3, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.68, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.25, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.85, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.6, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.3, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.24, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.78, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.1, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LORAZEPAM 2 MG/ML PO CONC", "drug_information": { "unit": "30.000000", "type": "UN" }, "code_information": [ { "code": "00054353244", "type": "NDC" } ], "standard_charges": [ { "minimum": 5.69, "maximum": 18.99, "gross_charge": 20.2, "discounted_cash": 11.11, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.72, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.03, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.16, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.11, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.88, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.7, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.1, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.08, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.99, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.78, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.69, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.15, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.12, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.74, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.99, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.82, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.03, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.06, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.15, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.78, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.72, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.03, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LORAZEPAM 4 MG/ML IJ SOLN", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "00641604710", "type": "NDC" } ], "standard_charges": [ { "minimum": 12.68, "maximum": 42.3, "gross_charge": 45.0, "discounted_cash": 24.75, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.1, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.12, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.1, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.91, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.3, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.68, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.25, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.85, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.6, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.3, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.24, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.78, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.1, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LOSARTAN 2.5MG/ML SUSPENSION", "drug_information": { "unit": "20.000000", "type": "UN" }, "code_information": [ { "code": "P0781590192", "type": "NDC" } ], "standard_charges": [ { "minimum": 12.72, "maximum": 42.42, "gross_charge": 45.13, "discounted_cash": 24.82, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.18, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.64, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.1, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.23, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.13, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.66, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.03, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.99, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.42, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.71, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.72, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.36, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.85, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.9, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.69, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.42, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.34, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.64, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.88, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.85, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.71, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.18, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.64, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LOSARTAN POTASSIUM 12.5 MG PO TABS", "drug_information": { "unit": "2.000000", "type": "UN" }, "code_information": [ { "code": "0054012322", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LOSARTAN POTASSIUM 25 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68084034601", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LOSARTAN POTASSIUM 50 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68084034701", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LOSARTAN POTASSIUM-HCTZ 100-12.5 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "43547042509", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LOTEPREDNOL ETABONATE 0.2 % OP SUSP", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "24208035305", "type": "NDC" } ], "standard_charges": [ { "minimum": 305.31, "maximum": 1018.43, "gross_charge": 1083.44, "discounted_cash": 595.89, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 628.4, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 591.56, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 866.75, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 917.67, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 315.28, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 520.05, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 648.98, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 647.9, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1018.43, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 953.43, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 305.31, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 920.92, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 812.58, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 381.7, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 736.74, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1018.43, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 848.33, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 591.56, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 861.33, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 812.58, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 953.43, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 628.4, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 591.56, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LOTEPREDNOL ETABONATE 0.5 % OP SUSP", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "24208029905", "type": "NDC" } ], "standard_charges": [ { "minimum": 324.78, "maximum": 1083.37, "gross_charge": 1152.52, "discounted_cash": 633.89, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 668.46, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 629.28, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 922.02, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 976.18, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 335.38, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 553.21, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 690.36, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 689.21, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1083.37, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1014.22, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 324.78, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 979.64, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 864.39, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 406.03, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 783.71, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1083.37, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 902.42, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 629.28, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 916.25, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 864.39, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1014.22, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 668.46, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 629.28, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LOVASTATIN 10 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "R6800131400", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LOVASTATIN 20 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "4306369230", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LOVASTATIN 40 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "4306354814", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Low back disk surgery", "code_information": [ { "code": "63030", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 5265.64, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3900.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 18243.53, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 33103.22, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5265.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 33103.22, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Low cost skin substitute app", "code_information": [ { "code": "C5271", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 451.2, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 334.22, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 20715.72, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 37589.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 451.2, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 37589.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Lower jaw bone graft", "code_information": [ { "code": "21215", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4360.43, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3229.95, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 47299.54, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 85942.12, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4360.43, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 85942.12, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LOXAPINE SUCCINATE 10 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00527139501", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Lsh uterus 250 g or less", "code_information": [ { "code": "58541", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 7674.11, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5684.53, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 41875.81, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 75984.38, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7674.11, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 75984.38, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Lsh uterus above 250 g", "code_information": [ { "code": "58543", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 7674.11, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5684.53, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 31445.76, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 59802.89, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7674.11, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 59802.89, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Lsh w/t/o ut 250 g or less", "code_information": [ { "code": "58542", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 7674.11, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5684.53, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 42240.78, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 76961.63, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7674.11, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 76961.63, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Lsh w/t/o uterus above 250 g", "code_information": [ { "code": "58544", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 7674.11, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5684.53, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 31821.95, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 58068.92, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7674.11, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 58068.92, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LU-177 LUTETIUM PSMA", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "08252000130", "type": "NDC" } ], "standard_charges": [ { "minimum": 357.89, "maximum": 1193.8, "gross_charge": 1270.0, "discounted_cash": 698.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 736.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 693.42, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1016.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1075.69, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 369.57, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 609.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 760.73, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 759.46, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1193.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1117.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 357.89, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1079.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 952.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 447.42, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 863.6, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1193.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 994.41, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 693.42, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1009.65, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 952.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1117.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 736.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 693.42, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LUBIPROSTONE 24 MCG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "69339016317", "type": "NDC" } ], "standard_charges": [ { "minimum": 7.2, "maximum": 24.02, "gross_charge": 25.55, "discounted_cash": 14.05, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.82, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.95, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.44, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.64, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.44, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.26, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.3, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.28, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.02, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.48, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.2, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.72, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.16, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.0, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.37, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.02, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.01, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.95, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.31, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.16, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.48, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.82, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.95, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LUBIPROSTONE 8 MCG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00254302802", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LUMICAIN ALUMINUM CHLORIDE 25% TOPICAL HEMOSTATIC SOLUTION", "drug_information": { "unit": "60.000000", "type": "UN" }, "code_information": [ { "code": "10733041260", "type": "NDC" } ], "standard_charges": [ { "minimum": 8.38, "maximum": 1158.0, "gross_charge": 29.73, "discounted_cash": 16.35, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.24, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.23, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.81, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.65, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.27, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.81, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.95, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.16, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.38, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.27, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.3, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.47, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.22, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.95, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.28, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.23, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.64, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.3, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.16, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.24, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.23, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Lung transplant double", "code_information": [ { "code": "32853", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 24033.58, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 43609.26, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 43609.26, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Lung transplant single", "code_information": [ { "code": "32851", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 18966.73, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 34415.44, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 34415.44, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LURASIDONE HCL 20 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687074721", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.46, "maximum": 4.87, "gross_charge": 5.18, "discounted_cash": 2.85, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.83, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.14, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.51, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.49, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.1, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.1, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.87, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.56, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.46, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.89, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.82, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.87, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.06, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.83, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.12, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.89, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.56, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.83, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LURASIDONE HCL 40 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687075821", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.47, "maximum": 4.89, "gross_charge": 5.2, "discounted_cash": 2.86, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.02, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.16, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.51, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.5, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.11, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.11, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.89, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.58, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.47, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.42, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.9, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.83, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.54, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.89, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.07, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.13, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.9, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.58, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.02, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LURASIDONE HCL 60 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687076994", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.46, "maximum": 4.87, "gross_charge": 5.18, "discounted_cash": 2.85, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.83, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.14, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.51, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.49, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.1, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.1, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.87, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.56, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.46, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.89, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.82, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.87, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.06, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.83, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.12, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.89, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.56, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.83, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LURASIDONE HCL 80 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687078021", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.51, "maximum": 5.03, "gross_charge": 5.35, "discounted_cash": 2.94, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.1, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.92, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.28, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.53, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.56, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.57, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.03, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.71, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.51, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.55, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.01, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.88, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.64, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.03, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.19, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.92, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.25, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.01, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.71, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.1, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.92, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LUTETIUM LU 177 DOTATATE 370 MBQ/ML IV SOLN", "drug_information": { "unit": "200.000000", "type": "UN" }, "code_information": [ { "code": "69488000301", "type": "NDC" } ], "standard_charges": [ { "minimum": 11394.0, "maximum": 150193.2, "gross_charge": 159780.0, "discounted_cash": 87879.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 92672.4, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 87239.88, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 127824.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 135333.66, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 46495.98, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 76694.4, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 95708.22, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 11394.0, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 150193.2, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 140606.4, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 45026.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 135813.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 119835.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 56290.49, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 108650.4, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 150193.2, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 125107.74, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 87239.88, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 15189.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 119835.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 140606.4, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 92672.4, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 87239.88, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "LUTETIUM LU 177 VIPIVOTIDE TET 1000 MBQ/ML IV SOLN", "drug_information": { "unit": "200.000000", "type": "UN" }, "code_information": [ { "code": "69488001061", "type": "NDC" } ], "standard_charges": [ { "minimum": 131.72, "maximum": 119850.0, "gross_charge": 127500.0, "discounted_cash": 70125.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 73950.0, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 131.72, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 102000.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 107992.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37102.5, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61200.0, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 76372.5, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 11394.0, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 119850.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 112200.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 35929.5, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 108375.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 95625.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 44918.25, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 86700.0, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 119850.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 99832.5, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 177.82, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 15189.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 95625.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 112200.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 73950.0, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 131.72, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "LYMPHOCYTEANTI-THYMO IMM GLOB 50 MG/ML IV SOLN", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "00009722402", "type": "NDC" } ], "standard_charges": [ { "minimum": 2166.77, "maximum": 11465.46, "gross_charge": 12197.3, "discounted_cash": 6708.52, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 7074.43, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2166.77, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9757.84, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10331.11, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3549.41, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5854.7, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7306.18, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 7293.99, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11465.46, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10733.62, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3437.2, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10367.71, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9147.98, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 4297.11, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 8294.16, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 11465.46, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 9550.49, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2925.14, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 9696.85, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9147.98, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10733.62, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7074.43, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2166.77, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "Lyse chest fibrin init day", "code_information": [ { "code": "32561", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 455.72, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 337.57, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 7725.72, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 14018.45, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 455.72, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 14018.45, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Lyse chest fibrin subq day", "code_information": [ { "code": "32562", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 455.72, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 337.57, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 5697.53, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 10867.6, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 455.72, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 10867.6, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Lysis intranasal synechia", "code_information": [ { "code": "30560", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 375.37, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 278.05, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 12475.63, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 22637.22, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 375.37, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 22637.22, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Lysis of labial lesion(s)", "code_information": [ { "code": "56441", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2343.63, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1736.02, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 13553.05, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 24592.24, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2343.63, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 24592.24, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Lysis penil circumic lesion", "code_information": [ { "code": "54162", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1509.96, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1118.49, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 5167.37, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 9376.28, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1509.96, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 9376.28, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MACITENTAN 10 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "66215050115", "type": "NDC" } ], "standard_charges": [ { "minimum": 383.39, "maximum": 1278.89, "gross_charge": 1360.52, "discounted_cash": 748.29, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 789.1, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 742.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1088.42, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1152.36, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 395.91, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 653.05, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 814.95, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 813.59, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1278.89, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1197.26, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 383.39, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1156.44, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1020.39, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 479.31, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 925.15, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1278.89, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1065.29, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 742.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1081.61, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1020.39, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1197.26, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 789.1, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 742.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MAGNESIUM HYDROXIDE 400 MG/5ML PO SUSP", "drug_information": { "unit": "30.000000", "type": "UN" }, "code_information": [ { "code": "00121043130", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MAGNESIUM OXIDE -MG SUPPLEMENT 400 (240 MG) MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "10006070028", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MAGNESIUM SULFATE (LAXATIVE) PO GRAN", "drug_information": { "unit": "454.000000", "type": "GR" }, "code_information": [ { "code": "00869060243", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MAGNESIUM SULFATE 2 GM/50ML IV SOLN", "drug_information": { "unit": "50.000000", "type": "UN" }, "code_information": [ { "code": "25021061281", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MAGNESIUM SULFATE 2 GM/50ML IV SOLN (MAKER)", "drug_information": { "unit": "50.000000", "type": "UN" }, "code_information": [ { "code": "08252000064", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MAGNESIUM SULFATE 2 GM/50ML IV SOLN CCU", "drug_information": { "unit": "50.000000", "type": "UN" }, "code_information": [ { "code": "25021061281_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MAGNESIUM SULFATE 2 GM/50ML IV SOLN FOR EMERGENT USE (PEDS)", "drug_information": { "unit": "50.000000", "type": "UN" }, "code_information": [ { "code": "25021061281_3", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MAGNESIUM SULFATE 20 GM/500ML IV SOLN (CARDIAC AND TARGETED TEMPERATURE MANAGEMENT)", "drug_information": { "unit": "500.000000", "type": "UN" }, "code_information": [ { "code": "63323010615", "type": "NDC" } ], "standard_charges": [ { "minimum": 28.18, "maximum": 94.0, "gross_charge": 100.0, "discounted_cash": 55.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 58.0, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.6, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 80.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 84.7, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.1, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 48.0, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.9, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.8, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 94.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.18, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 85.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.23, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 68.0, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 94.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 78.3, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.6, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 79.5, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 58.0, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.6, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MAGNESIUM SULFATE 20 GM/500ML IV SOLN (PRE-ECLAMPSIA/FOR OB USE)", "drug_information": { "unit": "500.000000", "type": "UN" }, "code_information": [ { "code": "63323010615_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 28.18, "maximum": 94.0, "gross_charge": 100.0, "discounted_cash": 55.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 58.0, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.6, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 80.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 84.7, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.1, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 48.0, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.9, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.8, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 94.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.18, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 85.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.23, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 68.0, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 94.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 78.3, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.6, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 79.5, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 58.0, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.6, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MAGNESIUM SULFATE 4 GM/100ML IV DRIP", "drug_information": { "unit": "100.000000", "type": "UN" }, "code_information": [ { "code": "00409672923", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MAGNESIUM SULFATE 4 GM/100ML IV SOLN", "drug_information": { "unit": "100.000000", "type": "UN" }, "code_information": [ { "code": "00409672923_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MAGNESIUM SULFATE 4 GM/100ML IV SOLN (MAKER)", "drug_information": { "unit": "100.000000", "type": "UN" }, "code_information": [ { "code": "08252000065", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MAGNESIUM SULFATE 4 GM/100ML IV SOLN CCU", "drug_information": { "unit": "100.000000", "type": "UN" }, "code_information": [ { "code": "00409672923_3", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MAGNESIUM SULFATE 40 MG/ML SYRINGE (PEDS)", "drug_information": { "unit": "50.000000", "type": "UN" }, "code_information": [ { "code": "25021061281_4", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MAGNESIUM SULFATE 50 % IJ SOLN", "drug_information": { "unit": "20.000000", "type": "UN" }, "code_information": [ { "code": "63323064220", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MAGNESIUM SULFATE 50 % IJ SOLN 2 ML VIAL (BULK CHARGE)", "drug_information": { "unit": "2.000000", "type": "UN" }, "code_information": [ { "code": "63323006403", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MAGNESIUM SULFATE 50% ORAL SOLUTION", "drug_information": { "unit": "500.000000", "type": "UN" }, "code_information": [ { "code": "08252037650", "type": "NDC" } ], "standard_charges": [ { "minimum": 3.87, "maximum": 1158.0, "gross_charge": 13.75, "discounted_cash": 7.56, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.98, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.51, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.94, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.0, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.24, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.22, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.93, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.1, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.87, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.69, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.31, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.84, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.35, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.93, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.77, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.51, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.93, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.31, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.1, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.98, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.51, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MAGNESIUM SULFATE IN D5W 1-5 GM/100ML-% IV SOLN", "drug_information": { "unit": "100.000000", "type": "UN" }, "code_information": [ { "code": "63323010801", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MALATHION 0.5 % EX LOTN", "drug_information": { "unit": "59.000000", "type": "UN" }, "code_information": [ { "code": "51672529404", "type": "NDC" } ], "standard_charges": [ { "minimum": 121.03, "maximum": 403.71, "gross_charge": 429.48, "discounted_cash": 236.21, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 249.1, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 234.5, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 343.58, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 363.77, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 124.98, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 206.15, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 257.26, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 256.83, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 403.71, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 377.94, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 121.03, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 365.06, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 322.11, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 151.31, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 292.05, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 403.71, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 336.28, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 234.5, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 341.44, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 322.11, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 377.94, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 249.1, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 234.5, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Male sling procedure", "code_information": [ { "code": "53440", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 9576.71, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 7093.86, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 19463.72, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 35317.23, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 9576.71, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 35317.23, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Manipulate finger w/anesth", "code_information": [ { "code": "26340", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1179.66, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 873.82, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 8919.03, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 16183.74, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1179.66, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 16183.74, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MANNITOL 10 % IV SOLN", "drug_information": { "unit": "500.000000", "type": "UN" }, "code_information": [ { "code": "00338035303", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 1158.0, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.72, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MANNITOL 20 % IV <=150 ML", "drug_information": { "unit": "250.000000", "type": "UN" }, "code_information": [ { "code": "00338035702_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 19.73, "maximum": 1158.0, "gross_charge": 70.0, "discounted_cash": 38.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.76, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.37, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.93, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.86, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.73, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.66, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.6, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.81, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.65, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MANNITOL 20 % IV <=250 ML", "drug_information": { "unit": "250.000000", "type": "UN" }, "code_information": [ { "code": "00338035702_3", "type": "NDC" } ], "standard_charges": [ { "minimum": 19.73, "maximum": 1158.0, "gross_charge": 70.0, "discounted_cash": 38.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.76, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.37, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.93, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.86, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.73, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.66, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.6, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.81, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.65, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MANNITOL 20 % IV <=50 ML SYRINGE", "drug_information": { "unit": "250.000000", "type": "UN" }, "code_information": [ { "code": "00338035702", "type": "NDC" } ], "standard_charges": [ { "minimum": 14.01, "maximum": 1158.0, "gross_charge": 49.71, "discounted_cash": 27.34, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.83, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.14, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.15, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.47, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.86, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.73, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.73, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.74, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.01, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.25, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.28, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.51, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.73, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.92, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.14, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.52, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.28, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.74, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.83, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.14, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MANNITOL 20 % IV <=500 ML", "drug_information": { "unit": "500.000000", "type": "UN" }, "code_information": [ { "code": "00990771503", "type": "NDC" } ], "standard_charges": [ { "minimum": 19.73, "maximum": 1158.0, "gross_charge": 70.0, "discounted_cash": 38.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.76, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.37, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.93, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.86, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.73, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.66, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.6, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.81, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.65, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MANNITOL 20 % IV SOLN", "drug_information": { "unit": "500.000000", "type": "UN" }, "code_information": [ { "code": "00990771503_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 19.73, "maximum": 1158.0, "gross_charge": 70.0, "discounted_cash": 38.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.76, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.37, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.93, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.86, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.73, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.66, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.6, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.81, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.65, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MANNITOL 20 % IV SOLN 500 ML BAG (BULK CHARGE)", "drug_information": { "unit": "500.000000", "type": "UN" }, "code_information": [ { "code": "00990771503_3", "type": "NDC" } ], "standard_charges": [ { "minimum": 28.18, "maximum": 1158.0, "gross_charge": 100.0, "discounted_cash": 55.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 58.0, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.6, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.8, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.1, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 48.0, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.9, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.8, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 94.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.18, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 85.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.23, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 68.0, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 94.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 78.3, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.6, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 79.5, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 58.0, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.6, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MANNITOL 20% IV 250 ML RTU", "drug_information": { "unit": "250.000000", "type": "UN" }, "code_information": [ { "code": "00338035702_4", "type": "NDC" } ], "standard_charges": [ { "minimum": 19.73, "maximum": 1158.0, "gross_charge": 70.0, "discounted_cash": 38.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.76, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.37, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.93, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.86, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.73, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.66, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.6, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.81, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.65, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MANNITOL 25 % IV SOLN", "drug_information": { "unit": "50.000000", "type": "UN" }, "code_information": [ { "code": "63323002425", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MARAVIROC 150 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "49702022318", "type": "NDC" } ], "standard_charges": [ { "minimum": 18.4, "maximum": 61.37, "gross_charge": 65.29, "discounted_cash": 35.91, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.87, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.65, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.23, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.3, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.0, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.34, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.11, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.04, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.37, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 57.46, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.4, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 48.97, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.0, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 44.4, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.37, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 51.12, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.65, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 51.91, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 48.97, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 57.46, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.87, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.65, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MARAVIROC 300 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "49702022418", "type": "NDC" } ], "standard_charges": [ { "minimum": 18.4, "maximum": 61.37, "gross_charge": 65.29, "discounted_cash": 35.91, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.87, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.65, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.23, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.3, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.0, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.34, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.11, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.04, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.37, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 57.46, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.4, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 48.97, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.0, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 44.4, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.37, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 51.12, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.65, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 51.91, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 48.97, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 57.46, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.87, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.65, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MARGETUXIMAB-CMKB 250 MG/10ML IV SOLN", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "74527002202", "type": "NDC" } ], "standard_charges": [ { "minimum": 1996.81, "maximum": 6660.76, "gross_charge": 7085.91, "discounted_cash": 3897.25, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4109.83, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3868.91, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5668.73, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6001.77, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2062.0, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3401.24, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4244.46, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4237.37, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6660.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6235.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1996.81, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6023.02, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5314.43, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2496.37, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4818.42, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6660.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5548.27, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3868.91, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5633.3, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5314.43, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6235.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4109.83, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3868.91, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MARIBAVIR 200 MG PO TABS", "drug_information": { "unit": "2.000000", "type": "UN" }, "code_information": [ { "code": "64764080028", "type": "NDC" } ], "standard_charges": [ { "minimum": 438.55, "maximum": 1462.87, "gross_charge": 1556.24, "discounted_cash": 855.93, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 902.62, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 849.71, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1244.99, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1318.14, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 452.87, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 747.0, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 932.19, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 930.63, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1462.87, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1369.49, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 438.55, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1322.8, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1167.18, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 548.26, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1058.24, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1462.87, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1218.54, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 849.71, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1237.21, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1167.18, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1369.49, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 902.62, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 849.71, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Mast mod rad", "code_information": [ { "code": "19307", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4806.97, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3560.72, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 61052.58, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 110780.97, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4806.97, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 110780.97, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Mast radical", "code_information": [ { "code": "19305", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 68225.08, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 123795.51, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 123795.51, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Mast simple complete", "code_information": [ { "code": "19303", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4806.97, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3560.72, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 24916.62, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 45598.91, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4806.97, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 45598.91, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Mastoid surgery revision", "code_information": [ { "code": "69601", "type": "HCPCS" }, { "code": "69602", "type": "HCPCS" }, { "code": "69603", "type": "HCPCS" }, { "code": "69604", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4360.43, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3229.95, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 18426.09, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 33434.44, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4360.43, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", 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PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 41889.29, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4360.43, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 41889.29, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Mastotomy expl drg absc dp", "code_information": [ { "code": "19020", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1194.28, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 884.65, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 12665.17, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 22981.18, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1194.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 22981.18, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Mdfc flap w/prsrv vasc pedcl", "code_information": [ { "code": "15730", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2698.5, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1998.89, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 9582.31, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 17387.27, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2698.5, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 17387.27, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MEASLES MUMPS & RUBELLA VAC IJ SOLR", "drug_information": { "unit": "0.500000", "type": "UN" }, "code_information": [ { "code": "00006468100", "type": "NDC" } ], "standard_charges": [ { "minimum": 69.51, "maximum": 231.88, "gross_charge": 246.68, "discounted_cash": 135.67, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 143.07, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 134.69, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 197.34, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 208.94, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 71.78, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 118.41, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 147.76, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 147.51, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 231.88, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 217.08, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 69.51, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 209.68, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 185.01, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.91, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 167.74, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 231.88, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 193.15, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 134.69, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 196.11, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 185.01, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 217.08, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 143.07, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 134.69, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MEASLES MUMPS & RUBELLA VAC SC SUSR", "drug_information": { "unit": "0.500000", "type": "UN" }, "code_information": [ { "code": "58160082415", "type": "NDC" } ], "standard_charges": [ { "minimum": 64.09, "maximum": 213.78, "gross_charge": 227.43, "discounted_cash": 125.09, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 131.91, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 124.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 181.94, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 192.63, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 66.18, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 109.17, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 136.23, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 136.0, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 213.78, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 200.14, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 64.09, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 193.32, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 170.57, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 80.12, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 154.65, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 213.78, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 178.08, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 124.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 180.81, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 170.57, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 200.14, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 131.91, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 124.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MEASLES-MUMPS-RUBELLA-VARICELL SC SUSR", "drug_information": { "unit": "0.500000", "type": "UN" }, "code_information": [ { "code": "00006417100", "type": "NDC" } ], "standard_charges": [ { "minimum": 291.83, "maximum": 973.46, "gross_charge": 1035.6, "discounted_cash": 569.58, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 600.65, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 565.44, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 828.48, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 877.15, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 301.36, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 497.09, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 620.32, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 619.29, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 973.46, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 911.33, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 291.83, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 880.26, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 776.7, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 364.84, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 704.21, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 973.46, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 810.87, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 565.44, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 823.3, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 776.7, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 911.33, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 600.65, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 565.44, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Mech remov tunneled cv cath", "code_information": [ { "code": "36595", "type": "HCPCS" }, { "code": "36596", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2320.02, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1718.54, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 848.18, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 15631.06, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 28362.8, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2320.02, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1145.04, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 28362.8, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MECLIZINE HCL 12.5 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687077501", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MECLIZINE HCL 25 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687073001", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Mediastinoscpy w/lmph nod bx", "code_information": [ { "code": "39402", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4300.51, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3185.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 17750.16, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 32208.06, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4300.51, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 32208.06, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Mediastinoscpy w/medstnl bx", "code_information": [ { "code": "39401", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4300.51, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3185.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 15346.9, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 29587.82, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4300.51, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 29587.82, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MEDIUM CHAIN TRIGLYCERIDES PO OIL", "drug_information": { "unit": "473.000000", "type": "UN" }, "code_information": [ { "code": "40093011257", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.16, "maximum": 37.22, "gross_charge": 39.6, "discounted_cash": 21.78, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.97, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.62, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.68, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.54, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.52, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.01, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.72, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.68, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.22, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.85, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.16, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.66, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.7, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.95, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.93, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.22, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.01, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.62, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.48, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.7, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.85, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.97, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.62, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MEDROXYPROGESTERONE ACETATE 10 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687010521", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MEDROXYPROGESTERONE ACETATE 104 MG/0.65ML SC SUSY", "drug_information": { "unit": "0.650000", "type": "UN" }, "code_information": [ { "code": "00009470913", "type": "NDC" } ], "standard_charges": [ { "minimum": 33.58, "maximum": 1158.0, "gross_charge": 119.18, "discounted_cash": 65.55, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 69.12, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.07, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.45, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.68, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 57.21, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 71.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 71.27, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 112.03, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 104.88, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.58, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 101.3, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 89.39, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.99, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 81.04, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 112.03, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.07, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 94.75, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 89.39, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 104.88, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 69.12, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.07, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MEDROXYPROGESTERONE ACETATE 150 MG/ML IM SUSP", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00548540025", "type": "NDC" } ], "standard_charges": [ { "minimum": 15.95, "maximum": 1158.0, "gross_charge": 56.61, "discounted_cash": 31.14, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.83, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.91, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.14, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.47, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.17, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.91, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.85, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 53.21, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.82, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.95, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 48.12, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.46, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.94, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.49, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 53.21, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 44.33, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.91, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.46, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.82, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.83, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.91, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MEDROXYPROGESTERONE ACETATE 2.5 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00555087202", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MEFLOQUINE HCL 250 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00555017178", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.47, "maximum": 8.23, "gross_charge": 8.76, "discounted_cash": 4.82, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.08, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.78, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.01, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.42, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.55, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.25, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.24, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.23, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.71, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.47, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.45, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.57, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.96, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.23, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.86, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.78, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.96, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.57, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.71, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.08, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.78, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MEGESTROL ACETATE 20 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00555060602", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MEGESTROL ACETATE 40 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00904723661", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MEGESTROL ACETATE 400 MG/10ML PO SUSP", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "68094006361", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.56, "maximum": 8.54, "gross_charge": 9.08, "discounted_cash": 4.99, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.27, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.96, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.26, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.69, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.36, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.44, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.43, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.54, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.99, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.56, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.72, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.81, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.17, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.54, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.11, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.96, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.22, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.81, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.99, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.27, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.96, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MELATONIN 1 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "74312002832", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MELATONIN 2.5 MG/10ML PO LIQD", "drug_information": { "unit": "4.000000", "type": "UN" }, "code_information": [ { "code": "47469007405", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MELATONIN 3 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "50268052415", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MELATONIN 3 MG PO TBDP", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "1191714868", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MELATONIN 5 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "20555003901", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MELATONIN 5 MG PO TBDP", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "R4009310164", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MELOXICAM 15 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "50268052615", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MELOXICAM 7.5 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "50268052515", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MELPHALAN HCL 50 MG IA SOLR", "drug_information": { "unit": "50.000000", "type": "UN" }, "code_information": [ { "code": "75833060102", "type": "NDC" } ], "standard_charges": [ { "minimum": 11394.0, "maximum": 514650.0, "gross_charge": 547500.0, "discounted_cash": 301125.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 317550.0, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 298935.0, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 438000.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 463732.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 159322.5, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 262800.0, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 327952.5, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 11394.0, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 514650.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 481800.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 154285.5, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 465375.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 410625.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 192884.25, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 372300.0, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 514650.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 428692.5, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 298935.0, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 15189.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 410625.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 481800.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 317550.0, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 298935.0, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MELPHALAN HCL 50 MG IV SOLR", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "43598039248", "type": "NDC" } ], "standard_charges": [ { "minimum": 71.3, "maximum": 237.84, "gross_charge": 253.02, "discounted_cash": 139.16, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 146.75, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 83.83, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 202.42, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 214.31, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 73.63, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 121.45, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 151.56, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 151.31, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 237.84, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 222.66, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 71.3, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 215.07, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 189.77, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 89.14, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 172.05, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 237.84, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 198.11, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 113.17, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 201.15, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 189.77, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 222.66, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 146.75, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 83.83, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "MEMANTINE HCL 10 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00904650661", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MEMANTINE HCL 5 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00591387044", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MENINGOCOCCAL A C Y&W-135 OLIG IM SOLN", "drug_information": { "unit": "0.500000", "type": "UN" }, "code_information": [ { "code": "58160082730", "type": "NDC" } ], "standard_charges": [ { "minimum": 99.94, "maximum": 333.36, "gross_charge": 354.64, "discounted_cash": 195.05, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 205.69, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 193.63, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 283.71, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 300.38, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.2, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 170.23, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 212.43, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 212.07, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 333.36, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 312.08, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 99.94, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 301.44, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 265.98, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 124.94, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 241.16, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 333.36, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 277.68, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 193.63, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 281.94, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 265.98, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 312.08, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 205.69, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 193.63, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MENINGOCOCCAL A C Y&W-135 OLIG IM SOLR", "drug_information": { "unit": "0.500000", "type": "UN" }, "code_information": [ { "code": "58160095509", "type": "NDC" } ], "standard_charges": [ { "minimum": 99.94, "maximum": 333.36, "gross_charge": 354.64, "discounted_cash": 195.05, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 205.69, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 193.63, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 283.71, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 300.38, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.2, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 170.23, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 212.43, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 212.07, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 333.36, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 312.08, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 99.94, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 301.44, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 265.98, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 124.94, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 241.16, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 333.36, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 277.68, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 193.63, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 281.94, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 265.98, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 312.08, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 205.69, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 193.63, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MENINGOCOCCAL VAC B (RECOMB) IM SUSY (2 DOSE SERIES)", "drug_information": { "unit": "0.500000", "type": "UN" }, "code_information": [ { "code": "58160097620", "type": "NDC" } ], "standard_charges": [ { "minimum": 151.47, "maximum": 505.25, "gross_charge": 537.5, "discounted_cash": 295.63, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 311.75, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 293.48, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 430.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 455.26, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 156.41, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 258.0, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 321.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 321.43, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 505.25, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 473.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 151.47, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 456.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 403.13, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 189.36, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 365.5, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 505.25, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 420.86, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 293.48, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 427.31, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 403.13, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 473.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 311.75, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 293.48, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Meniscal trnspl knee w/scpe", "code_information": [ { "code": "29868", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 5265.64, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3900.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 27950.37, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 50756.24, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5265.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 50756.24, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MENOTROPINS 75 UNITS SC SOLR", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "55566750102", "type": "NDC" } ], "standard_charges": [ { "minimum": 232.24, "maximum": 1158.0, "gross_charge": 824.12, "discounted_cash": 453.27, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 477.99, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 449.97, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 715.34, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 239.82, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 395.58, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 493.65, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 492.82, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 774.67, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 725.23, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 232.24, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 700.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 618.09, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 290.34, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 560.4, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 774.67, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 645.29, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 449.97, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 655.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 618.09, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 725.23, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 477.99, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 449.97, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MENTHOL 5 MG MT LOZG", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "36602019210", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MENTHOL MT LOZG (MULTI-GPI)", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "36602019210_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MEPERIDINE HCL 100 MG/ML (IV ROUTE) SOLN", "drug_information": { "unit": "0.500000", "type": "UN" }, "code_information": [ { "code": "00641605425", "type": "NDC" } ], "standard_charges": [ { "minimum": 12.68, "maximum": 42.3, "gross_charge": 45.0, "discounted_cash": 24.75, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.1, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.12, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.1, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.91, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.3, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.68, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.25, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.85, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.6, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.3, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.24, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.78, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.1, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MEPERIDINE HCL 100 MG/ML IJ SOLN", "drug_information": { "unit": "0.500000", "type": "UN" }, "code_information": [ { "code": "00641605425_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 12.68, "maximum": 42.3, "gross_charge": 45.0, "discounted_cash": 24.75, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.1, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.12, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.1, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.91, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.3, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.68, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.25, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.85, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.6, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.3, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.24, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.78, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.1, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MEPERIDINE HCL 25 MG/ML (IV ROUTE) SOLN", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00409117630", "type": "NDC" } ], "standard_charges": [ { "minimum": 12.68, "maximum": 42.3, "gross_charge": 45.0, "discounted_cash": 24.75, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.1, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.12, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.1, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.91, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.3, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.68, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.25, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.85, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.6, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.3, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.24, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.78, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.1, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MEPERIDINE HCL 25 MG/ML IJ SOLN", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00409117630_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 12.68, "maximum": 42.3, "gross_charge": 45.0, "discounted_cash": 24.75, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.1, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.12, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.1, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.91, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.3, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.68, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.25, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.85, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.6, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.3, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.24, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.78, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.1, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MEPERIDINE HCL 50 MG/5ML PO SOLN", "drug_information": { "unit": "500.000000", "type": "UN" }, "code_information": [ { "code": "00054354563", "type": "NDC" } ], "standard_charges": [ { "minimum": 46.28, "maximum": 154.38, "gross_charge": 164.23, "discounted_cash": 90.33, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 95.25, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 89.67, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 131.38, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 139.1, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.79, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 78.83, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 98.37, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 98.21, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 154.38, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 144.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.28, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 139.6, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 123.17, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 57.86, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 111.68, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 154.38, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 128.59, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 89.67, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 130.56, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 123.17, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 144.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 95.25, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 89.67, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MEPERIDINE HCL 50 MG/ML (IV ROUTE) SOLN", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00409117830", "type": "NDC" } ], "standard_charges": [ { "minimum": 12.68, "maximum": 42.3, "gross_charge": 45.0, "discounted_cash": 24.75, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.1, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.12, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.1, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.91, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.3, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.68, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.25, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.85, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.6, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.3, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.24, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.78, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.1, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MEPERIDINE HCL 50 MG/ML IJ SOLN", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00409117830_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 12.68, "maximum": 42.3, "gross_charge": 45.0, "discounted_cash": 24.75, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.1, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.12, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.1, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.91, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", 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24.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MEPERIDINE HCL 75 MG/ML (IV ROUTE) SOLN", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00409117930", "type": "NDC" } ], "standard_charges": [ { "minimum": 12.68, "maximum": 42.3, "gross_charge": 45.0, "discounted_cash": 24.75, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.1, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", 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charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.85, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.6, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.3, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.24, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.78, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.1, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MEPERIDINE HCL 75 MG/ML IJ SOLN", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00409117930_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 12.68, "maximum": 42.3, "gross_charge": 45.0, "discounted_cash": 24.75, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.1, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", 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total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.91, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.3, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.68, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.25, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.85, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.6, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.3, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.24, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.78, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.1, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MEPIVACAINE HCL (PF) 1 % IJ SOLN", "drug_information": { "unit": "30.000000", "type": "UN" }, "code_information": [ { "code": "63323026037", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MEPIVACAINE HCL (PF) 1.5 % IJ SOLN", "drug_information": { "unit": "30.000000", "type": "UN" }, "code_information": [ { "code": "63323029337", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MEPIVACAINE HCL (PF) 2 % IJ SOLN", "drug_information": { "unit": "20.000000", "type": "UN" }, "code_information": [ { "code": "63323029427", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 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charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MEPIVACAINE HCL 2 % IJ SOLN", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "63323029657", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MEPOLIZUMAB 100 MG SC SOLR", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00173088101", "type": "NDC" } ], "standard_charges": [ { "minimum": 2927.55, "maximum": 9765.43, "gross_charge": 10388.76, "discounted_cash": 5713.82, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 6025.48, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5672.26, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8311.01, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8799.28, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3023.13, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4986.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6222.87, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 6212.48, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9765.43, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9142.11, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2927.55, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8830.45, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7791.57, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3659.96, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7064.36, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 9765.43, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8134.4, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5672.26, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 8259.06, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7791.57, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9142.11, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6025.48, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5672.26, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MERCAPTOPURINE 2000 MG/100ML PO SUSP", "drug_information": { "unit": "1.250000", "type": "UN" }, "code_information": [ { "code": "62484002002", "type": "NDC" } ], "standard_charges": [ { "minimum": 12.11, "maximum": 40.41, "gross_charge": 42.99, "discounted_cash": 23.64, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.93, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.47, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.39, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.41, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.51, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.64, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.75, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.71, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.41, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.83, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.11, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.54, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.24, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.15, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.23, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.41, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.66, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.47, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.24, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.83, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.93, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.47, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MERCAPTOPURINE 50 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00054458111", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MEROPENEM 1 G IV SOLR", "drug_information": { "unit": "20.000000", "type": "UN" }, "code_information": [ { "code": "00409139122", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MEROPENEM 1 GM/50 ML NS (X2) SPLIT INFUSION", "drug_information": { "unit": "100.000000", "type": "UN" }, "code_information": [ { "code": "00264318511_3", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MEROPENEM 1 GM/50 ML NS (X2) SPLIT INFUSION|DISCARDED DRUG NOT ADMINISTERED", "drug_information": { "unit": "100.000000", "type": "UN" }, "code_information": [ { "code": "00264318511_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 15.27, "maximum": 50.93, "gross_charge": 54.18, "discounted_cash": 29.8, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.42, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.58, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.34, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.89, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.77, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.01, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.45, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.93, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.68, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.05, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.64, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.84, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.93, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.42, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.58, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.07, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.64, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.68, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.42, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.58, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MEROPENEM 500 MG IV SOLR", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "00781300095", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MEROPENEM-SODIUM CHLORIDE 1 GM/50ML IV SOLR", "drug_information": { "unit": "50.000000", "type": "UN" }, "code_information": [ { "code": "00264318511_4", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MEROPENEM-SODIUM CHLORIDE 1 GM/50ML IV SOLR|DISCARDED DRUG NOT ADMINISTERED", "drug_information": { "unit": "50.000000", "type": "UN" }, "code_information": [ { "code": "00264318511", "type": "NDC" } ], "standard_charges": [ { "minimum": 7.63, "maximum": 25.46, "gross_charge": 27.09, "discounted_cash": 14.9, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.71, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.79, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.67, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.95, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.88, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.0, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.23, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.2, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.46, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.84, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.63, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.03, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.32, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.54, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.42, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.46, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.21, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.79, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.54, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.32, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.84, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.71, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.79, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MEROPENEM-VABORBACTAM 2 (1-1) G IV SOLR", "drug_information": { "unit": "21.300000", "type": "UN" }, "code_information": [ { "code": "70842012006", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.14, "maximum": 639.58, "gross_charge": 680.4, "discounted_cash": 374.22, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 394.63, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.14, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 544.32, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 576.3, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 198.0, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 326.59, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 407.56, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 406.88, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 639.58, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 598.75, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 191.74, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 578.34, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 510.3, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 239.7, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 462.67, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 639.58, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 532.75, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.54, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 540.92, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 510.3, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 598.75, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 394.63, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.14, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "MESALAMINE 1.2 G PO TBEC", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687039725", "type": "NDC" } ], "standard_charges": [ { "minimum": 4.65, "maximum": 15.52, "gross_charge": 16.51, "discounted_cash": 9.08, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.58, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.01, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.21, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.98, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.8, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.87, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.53, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.65, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.03, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.38, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.82, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.23, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.93, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.01, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.13, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.38, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.53, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.58, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.01, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MESALAMINE 1000 MG RE SUPP", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "70710130207", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.36, "maximum": 4.53, "gross_charge": 4.82, "discounted_cash": 2.65, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.63, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.86, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.08, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.4, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.31, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.88, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.53, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.24, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.36, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.1, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.62, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.7, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.28, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.53, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.77, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.63, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.83, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.62, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.24, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.63, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MESALAMINE 4 G RE ENEM", "drug_information": { "unit": "60.000000", "type": "UN" }, "code_information": [ { "code": "62559042007", "type": "NDC" } ], "standard_charges": [ { "minimum": 7.47, "maximum": 24.91, "gross_charge": 26.5, "discounted_cash": 14.58, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.37, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.47, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.45, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.71, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.72, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.87, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.85, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.91, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.32, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.47, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.53, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.88, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.34, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.02, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.91, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.75, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.47, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.07, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.88, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.32, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.37, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.47, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MESALAMINE 400 MG PO CPDR", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687055632", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.89, "maximum": 9.65, "gross_charge": 10.27, "discounted_cash": 5.65, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.96, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.61, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.22, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.7, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.99, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.93, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.15, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.14, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.65, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.89, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.73, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.7, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.62, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.98, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.65, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.04, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.61, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.16, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.7, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.96, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.61, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MESALAMINE ER 0.375 G PO CP24", "drug_information": { "unit": "4.000000", "type": "UN" }, "code_information": [ { "code": "65649010302", "type": "NDC" } ], "standard_charges": [ { "minimum": 10.85, "maximum": 36.21, "gross_charge": 38.52, "discounted_cash": 21.19, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.34, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.03, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.82, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.63, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.21, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.49, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.07, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.03, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.21, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.9, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.85, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.74, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.89, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.57, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.19, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.21, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.16, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.03, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.62, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.89, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.9, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.34, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.03, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MESALAMINE ER 250 MG PO CPCR", "drug_information": { "unit": "2.000000", "type": "UN" }, "code_information": [ { "code": "54092018981", "type": "NDC" } ], "standard_charges": [ { "minimum": 3.87, "maximum": 12.93, "gross_charge": 13.75, "discounted_cash": 7.56, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.98, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.51, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.65, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.0, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.24, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.22, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.93, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.1, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.87, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.69, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.31, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.84, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.35, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.93, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.77, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.51, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.93, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.31, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.1, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.98, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.51, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MESALAMINE ER 500 MG PO CPCR", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "63304008913", "type": "NDC" } ], "standard_charges": [ { "minimum": 3.49, "maximum": 11.64, "gross_charge": 12.38, "discounted_cash": 6.81, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.18, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.76, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.9, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.49, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.6, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.94, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.42, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.89, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.49, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.52, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.29, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.36, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.42, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.69, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.76, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.84, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.29, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.89, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.18, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.76, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MESNA 100 MG/ML IV SOLN", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "10019095301", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MESNA SYRINGE", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "10019095301_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "METFORMIN HCL 1000 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687016201", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "METFORMIN HCL 500 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00904716261", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "METFORMIN HCL 500 MG/5ML PO SOLN", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "10631020602", "type": "NDC" } ], "standard_charges": [ { "minimum": 4.45, "maximum": 14.85, "gross_charge": 15.8, "discounted_cash": 8.69, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.16, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.63, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.64, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.38, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.6, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.58, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.46, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.45, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.85, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.9, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.45, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.43, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.85, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.57, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.74, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.85, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.37, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.63, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.56, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.85, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.9, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.16, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.63, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "METFORMIN HCL 850 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687014301", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "METFORMIN HCL ER (MOD) 1000 MG PO TB24", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68012000316", "type": "NDC" } ], "standard_charges": [ { "minimum": 99.45, "maximum": 331.74, "gross_charge": 352.91, "discounted_cash": 194.1, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 204.69, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 192.69, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 282.33, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 298.91, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 102.7, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 169.4, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 211.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 211.04, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 331.74, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 310.56, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 99.45, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 299.97, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 264.68, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 124.33, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 239.98, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 331.74, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 276.33, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 192.69, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 280.56, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 264.68, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 310.56, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 204.69, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 192.69, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "METFORMIN HCL ER 500 MG PO TB24", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "50268055015", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "METFORMIN HCL ER 750 MG PO TB24", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "76385012901", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "METHACHOLINE CHLORIDE 100 MG IN SOLR", "drug_information": { "unit": "100.000000", "type": "ME" }, "code_information": [ { "code": "64281010006", "type": "NDC" } ], "standard_charges": [ { "minimum": 64.95, "maximum": 216.67, "gross_charge": 230.5, "discounted_cash": 126.78, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 133.69, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 125.85, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 184.4, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 195.23, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 67.08, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 110.64, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 138.07, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 137.84, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 216.67, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 202.84, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 64.95, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 195.93, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 172.88, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 81.21, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 156.74, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 216.67, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 180.48, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 125.85, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 183.25, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 172.88, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 202.84, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 133.69, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 125.85, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "METHADONE 1 MG/ML 1ML SYRINGE (NICU/PEDS)", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "73177014943", "type": "NDC" } ], "standard_charges": [ { "minimum": 12.68, "maximum": 42.3, "gross_charge": 45.0, "discounted_cash": 24.75, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.1, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.12, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.1, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.91, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.3, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.68, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.25, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.85, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.6, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.3, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.24, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.78, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.1, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "METHADONE HCL 1 MG/ML PO SOLN (NICU)", "drug_information": { "unit": "500.000000", "type": "UN" }, "code_information": [ { "code": "00054355563", "type": "NDC" } ], "standard_charges": [ { "minimum": 17.49, "maximum": 58.36, "gross_charge": 62.08, "discounted_cash": 34.14, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.01, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.9, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.66, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.58, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.07, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.19, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.12, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 58.36, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.63, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.49, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.77, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.56, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.87, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.21, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 58.36, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 48.61, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.9, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.35, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.56, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.63, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.01, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.9, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "METHADONE HCL 10 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00054071020", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.25, "maximum": 7.52, "gross_charge": 8.0, "discounted_cash": 4.4, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.4, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.78, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.33, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.84, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.79, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.25, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.8, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.82, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.44, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.26, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.36, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "METHADONE HCL 10 MG/ML IJ SOLN", "drug_information": { "unit": "20.000000", "type": "UN" }, "code_information": [ { "code": "67457021720", "type": "NDC" } ], "standard_charges": [ { "minimum": 272.77, "maximum": 909.87, "gross_charge": 967.95, "discounted_cash": 532.37, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 561.41, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 528.5, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 774.36, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 819.85, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 281.67, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 464.62, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 579.8, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 578.83, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 909.87, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 851.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 272.77, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 822.76, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 725.96, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 341.01, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 658.21, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 909.87, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 757.9, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 528.5, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 769.52, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 725.96, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 851.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 561.41, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 528.5, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "METHADONE HCL 10 MG/ML PO CONC", "drug_information": { "unit": "30.000000", "type": "UN" }, "code_information": [ { "code": "00054355344", "type": "NDC" } ], "standard_charges": [ { "minimum": 12.94, "maximum": 43.17, "gross_charge": 45.93, "discounted_cash": 25.26, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.08, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.74, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.9, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.37, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.05, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.51, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.47, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.17, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.42, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.94, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.04, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.45, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.18, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.23, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.17, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.96, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.08, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.51, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.45, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.42, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.08, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "METHADONE HCL 5 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00406575562", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.25, "maximum": 7.52, "gross_charge": 8.0, "discounted_cash": 4.4, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.4, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.78, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.33, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.84, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.79, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.25, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.8, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.82, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.44, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.26, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.36, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "METHADONE HCL 5 MG/5ML PO SOLN", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "68094003162", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.25, "maximum": 7.52, "gross_charge": 8.0, "discounted_cash": 4.4, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.4, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.78, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.33, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.84, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.79, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.25, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.8, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.82, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.44, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.26, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.36, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "METHADONE HCL-NACL 1-0.9 MG/ML-% IV SOSY", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "73177014902", "type": "NDC" } ], "standard_charges": [ { "minimum": 14.09, "maximum": 47.0, "gross_charge": 50.0, "discounted_cash": 27.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.0, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.3, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.35, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.55, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.0, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.95, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.9, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 44.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.62, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.15, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.3, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.75, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 44.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.0, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.3, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "METHADONE HCL-SODIUM CHLORIDE 1-0.9 MG/ML-% IV SOSY", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "73177014943_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 12.68, "maximum": 42.3, "gross_charge": 45.0, "discounted_cash": 24.75, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.1, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.12, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.1, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.91, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.3, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.68, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.25, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.85, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.6, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.3, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.24, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.78, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.1, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "METHAZOLAMIDE 50 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "62559024101", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.35, "maximum": 4.5, "gross_charge": 4.79, "discounted_cash": 2.63, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.78, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.62, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.83, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.06, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.39, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.3, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.87, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.86, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.5, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.22, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.35, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.07, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.59, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.69, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.26, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.5, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.75, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.62, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.81, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.59, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.22, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.78, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.62, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "METHENAMINE HIPPURATE 1 G PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "50268054915", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "METHIMAZOLE 10 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687068001", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "METHIMAZOLE 5 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687066901", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "METHOCARBAMOL 1000 MG/10ML IJ SOLN", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "70069010125", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "METHOCARBAMOL 500 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687055901", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "METHOCARBAMOL 750 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687056801", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "METHOHEXITAL SODIUM 0.5 G IJ SOLR", "drug_information": { "unit": "50.000000", "type": "ME" }, "code_information": [ { "code": "42023010501", "type": "NDC" } ], "standard_charges": [ { "minimum": 12.68, "maximum": 1158.0, "gross_charge": 45.0, "discounted_cash": 24.75, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.1, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.06, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.1, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.91, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.3, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.68, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.25, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.85, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.6, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.3, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.24, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.78, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.1, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "METHOTREXATE 0.5 MG/ML SUSPENSION", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "P5107967005", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.48, "maximum": 4.94, "gross_charge": 5.25, "discounted_cash": 2.89, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.05, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.87, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.45, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.53, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.52, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.14, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.14, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.94, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.62, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.48, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.46, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.94, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.85, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.57, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.94, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.11, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.87, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.17, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.94, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.62, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.05, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.87, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "METHOTREXATE 2.5 MG/ML PO SOLN", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "52652200101", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.31, "maximum": 4882.31, "gross_charge": 5193.95, "discounted_cash": 2856.67, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3012.49, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.31, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4155.16, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4399.28, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1511.44, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2493.1, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3111.18, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 3105.98, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4882.31, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4570.68, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1463.66, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4414.86, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3895.46, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1829.83, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3531.89, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4882.31, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4066.86, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.27, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4129.19, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3895.46, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4570.68, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3012.49, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.31, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "METHOTREXATE INTRAVITREAL INJ 200 MCG/0.1ML", "drug_information": { "unit": "0.100000", "type": "UN" }, "code_information": [ { "code": "08252001600", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "METHOTREXATE INTRAVITREAL INJ 400 MCG/0.05ML", "drug_information": { "unit": "0.050000", "type": "UN" }, "code_information": [ { "code": "08252000181", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "METHOTREXATE INTRAVITREAL INJ 400 MCG/0.1ML", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "C6170340841", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "METHOTREXATE SODIUM (PF) 1 GM/40ML IJ SOLN", "drug_information": { "unit": "40.000000", "type": "UN" }, "code_information": [ { "code": "61703040841", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "METHOTREXATE SODIUM (PF) 250 MG/10ML IJ SOLN", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "00703367501", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "METHOTREXATE SODIUM (PF) 50 MG/2ML IJ SOLN", "drug_information": { "unit": "2.000000", "type": "UN" }, "code_information": [ { "code": "16729027730", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "METHOTREXATE SODIUM 1 G IJ SOLR", "drug_information": { "unit": "20.000000", "type": "UN" }, "code_information": [ { "code": "00143983001", "type": "NDC" } ], "standard_charges": [ { "minimum": 27.84, "maximum": 92.87, "gross_charge": 98.8, "discounted_cash": 54.34, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 57.3, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 53.94, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 79.04, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 83.68, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.75, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.42, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.18, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.08, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 92.87, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.94, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.84, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 83.98, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.1, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.81, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 67.18, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 92.87, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 77.36, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 53.94, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 78.55, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.1, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.94, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 57.3, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 53.94, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "METHOXSALEN (PHOTOPHERESIS) 20 MCG/ML EC SOLN", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "64067021601", "type": "NDC" } ], "standard_charges": [ { "minimum": 711.26, "maximum": 2372.56, "gross_charge": 2524.0, "discounted_cash": 1388.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1463.92, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1378.1, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2190.83, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 734.48, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1211.52, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1511.88, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 1509.35, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2372.56, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2221.12, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 711.26, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2145.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1893.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 889.21, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1716.32, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2372.56, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1976.29, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1378.1, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2006.58, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1893.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2221.12, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1463.92, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1378.1, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "METHYLENE BLUE 0.5 % IV SOLN", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "00517037405", "type": "NDC" } ], "standard_charges": [ { "minimum": 4.66, "maximum": 1158.0, "gross_charge": 271.71, "discounted_cash": 149.44, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 157.59, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.66, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 235.84, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 79.07, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 130.42, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 162.75, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 162.48, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 255.41, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 239.1, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 76.57, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 230.95, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 203.78, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 95.72, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 184.76, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 255.41, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 212.75, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.29, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 216.01, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 203.78, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 239.1, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 157.59, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.66, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "METHYLERGONOVINE MALEATE 0.2 MG/ML IJ SOLN", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "51991014417", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "METHYLNALTREXONE BROMIDE 12 MG/0.6ML SC SOLN", "drug_information": { "unit": "0.400000", "type": "UN" }, "code_information": [ { "code": "65649055102", "type": "NDC" } ], "standard_charges": [ { "minimum": 143.2, "maximum": 477.68, "gross_charge": 508.17, "discounted_cash": 279.49, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 294.74, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 277.46, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 406.54, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 430.42, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 147.88, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 243.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 304.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 303.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 477.68, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 447.19, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 143.2, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 431.94, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 381.13, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 179.03, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 345.56, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 477.68, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 397.9, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 277.46, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 404.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 381.13, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 447.19, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 294.74, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 277.46, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "METHYLNALTREXONE BROMIDE 150 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "65649015090", "type": "NDC" } ], "standard_charges": [ { "minimum": 16.88, "maximum": 56.32, "gross_charge": 59.91, "discounted_cash": 32.95, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.75, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.71, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.93, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.74, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.43, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.76, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.83, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 56.32, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.72, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.88, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.92, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 44.93, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.11, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.74, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 56.32, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.91, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.71, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.63, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 44.93, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.72, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.75, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.71, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "METHYLNALTREXONE BROMIDE 8 MG/0.4ML SC SOLN", "drug_information": { "unit": "0.400000", "type": "UN" }, "code_information": [ { "code": "65649055204", "type": "NDC" } ], "standard_charges": [ { "minimum": 143.2, "maximum": 477.68, "gross_charge": 508.17, "discounted_cash": 279.49, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 294.74, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 277.46, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 406.54, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 430.42, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 147.88, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 243.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 304.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 303.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 477.68, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 447.19, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 143.2, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 431.94, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 381.13, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 179.03, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 345.56, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 477.68, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 397.9, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 277.46, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 404.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 381.13, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 447.19, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 294.74, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 277.46, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "METHYLPHENIDATE 10 MG/9HR TD PTCH", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68968555203", "type": "NDC" } ], "standard_charges": [ { "minimum": 3.84, "maximum": 12.81, "gross_charge": 13.63, "discounted_cash": 7.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.91, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.44, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.9, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.54, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.97, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.54, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.16, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.15, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.81, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.99, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.84, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.59, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.22, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.8, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.27, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.81, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.67, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.44, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.84, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.22, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.99, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.91, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.44, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "METHYLPHENIDATE 15 MG/9HR TD PTCH", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68968555303", "type": "NDC" } ], "standard_charges": [ { "minimum": 3.84, "maximum": 12.81, "gross_charge": 13.63, "discounted_cash": 7.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.91, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.44, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.9, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.54, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.97, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.54, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.16, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.15, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.81, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.99, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.84, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.59, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.22, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.8, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.27, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.81, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.67, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.44, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.84, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.22, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.99, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.91, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.44, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "METHYLPHENIDATE 20 MG/9HR TD PTCH", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68968555403", "type": "NDC" } ], "standard_charges": [ { "minimum": 3.84, "maximum": 12.81, "gross_charge": 13.63, "discounted_cash": 7.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.91, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.44, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.9, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.54, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.97, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.54, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.16, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.15, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.81, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.99, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.84, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.59, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.22, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.8, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.27, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.81, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.67, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.44, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.84, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.22, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.99, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.91, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.44, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "METHYLPHENIDATE 30 MG/9HR TD PTCH", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68968555503", "type": "NDC" } ], "standard_charges": [ { "minimum": 3.84, "maximum": 12.81, "gross_charge": 13.63, "discounted_cash": 7.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.91, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.44, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.9, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.54, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.97, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.54, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.16, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.15, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.81, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.99, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.84, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.59, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.22, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.8, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.27, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.81, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.67, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.44, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.84, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.22, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.99, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.91, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.44, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "METHYLPHENIDATE HCL 10 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "R3172217401", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.25, "maximum": 7.52, "gross_charge": 8.0, "discounted_cash": 4.4, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.4, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.78, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.33, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.84, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.79, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.25, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.8, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.82, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.44, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.26, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.36, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "METHYLPHENIDATE HCL 20 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00406114601", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.25, "maximum": 7.52, "gross_charge": 8.0, "discounted_cash": 4.4, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.4, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.78, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.33, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.84, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.79, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.25, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.8, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.82, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.44, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.26, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.36, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "METHYLPHENIDATE HCL 5 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68084080521", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.25, "maximum": 7.52, "gross_charge": 8.0, "discounted_cash": 4.4, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.4, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.78, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.33, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.84, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.79, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.25, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.8, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.82, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.44, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.26, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.36, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "METHYLPHENIDATE HCL ER (LA) 20 MG PO CP24", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00078037005", "type": "NDC" } ], "standard_charges": [ { "minimum": 8.05, "maximum": 26.87, "gross_charge": 28.58, "discounted_cash": 15.72, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.58, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.6, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.86, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.21, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.32, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.72, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.12, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.09, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.87, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.15, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.05, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.29, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.44, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.07, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.43, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.87, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.38, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.6, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.72, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.44, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.15, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.58, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.6, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "METHYLPHENIDATE HCL ER (OSM) 18 MG PO TBCR", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "R1381170610", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.25, "maximum": 7.52, "gross_charge": 8.0, "discounted_cash": 4.4, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.4, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.78, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.33, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.84, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.79, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.25, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.8, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.82, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.44, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.26, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.36, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "METHYLPHENIDATE HCL ER (OSM) 27 MG PO TBCR", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "R1381170710", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.25, "maximum": 7.52, "gross_charge": 8.0, "discounted_cash": 4.4, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.4, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.78, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.33, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.84, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.79, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.25, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.8, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.82, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.44, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.26, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.36, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "METHYLPHENIDATE HCL ER (OSM) 36 MG PO TBCR", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "1014706861", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.25, "maximum": 7.52, "gross_charge": 8.0, "discounted_cash": 4.4, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.4, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.78, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.33, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.84, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.79, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.25, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.8, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.82, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.44, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.26, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.36, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "METHYLPREDNISOLONE 16 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68001055969", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "METHYLPREDNISOLONE 2 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00009002001", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "METHYLPREDNISOLONE 32 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "R6838291911", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.68, "maximum": 5.6, "gross_charge": 5.96, "discounted_cash": 3.28, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.46, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.25, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.77, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.05, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.73, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.86, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.57, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.56, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.24, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.68, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.07, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.47, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.1, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.05, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.67, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.25, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.74, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.47, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.24, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.46, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.25, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "METHYLPREDNISOLONE 4 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68084014901", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "METHYLPREDNISOLONE 4 MG PO TBPK", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "59746000103", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "METHYLPREDNISOLONE 4 MG/ML SYRINGE (NICU/PEDS)", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "00009003928_5", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.16, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.16, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.22, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.16, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "METHYLPREDNISOLONE 4 MG/ML SYRINGE (NICU/PEDS)|DISCARDED DRUG NOT ADMINISTERED", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "00009003928", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.16, "maximum": 10.77, "gross_charge": 11.46, "discounted_cash": 6.3, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.65, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.16, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.17, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.71, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.33, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.5, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.86, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.85, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.77, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.08, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.23, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.74, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.6, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.04, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.79, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.77, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.97, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.22, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.11, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.6, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.08, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.65, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.16, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "METHYLPREDNISOLONE 40 MG/ML SYRINGE (PEDS)", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00009003928_7", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.16, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.16, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.22, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.16, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "METHYLPREDNISOLONE 40 MG/ML SYRINGE (PEDS)|DISCARDED DRUG NOT ADMINISTERED", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00009003928_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.16, "maximum": 10.77, "gross_charge": 11.46, "discounted_cash": 6.3, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.65, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.16, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.17, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.71, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.33, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.5, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.86, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.85, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.77, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.08, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.23, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.74, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.6, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.04, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.79, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.77, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.97, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.22, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.11, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.6, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.08, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.65, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.16, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "METHYLPREDNISOLONE 8 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "59746000204", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "METHYLPREDNISOLONE ACETATE 80 MG/ML IJ SUSP", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "70121157401_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.07, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.07, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.09, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.07, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "METHYLPREDNISOLONE ACETATE 80 MG/ML IJ SUSP|DISCARDED DRUG NOT ADMINISTERED", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "70121157401", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.07, "maximum": 13.33, "gross_charge": 14.18, "discounted_cash": 7.8, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.22, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.07, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.34, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.01, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.13, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.81, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.49, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.48, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.33, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.48, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.05, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.64, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.0, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.64, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.33, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.1, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.09, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.64, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.48, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.22, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.07, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "METHYLPREDNISOLONE NA SUC (PF) 40 MG IJ SOLR", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00009003928_6", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.16, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.16, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.22, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.16, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "METHYLPREDNISOLONE NA SUC (PF) 40 MG IJ SOLR|DISCARDED DRUG NOT ADMINISTERED", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00009003928_3", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.16, "maximum": 10.77, "gross_charge": 11.46, "discounted_cash": 6.3, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.65, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.16, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.17, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.71, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.33, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.5, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.86, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.85, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.77, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.08, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.23, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.74, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.6, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.04, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.79, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.77, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.97, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.22, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.11, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.6, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.08, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.65, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.16, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "METHYLPREDNISOLONE NA SUC (PF) 40 MG/ML IV SYRINGE", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00009003928_8", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.16, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.16, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.22, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.16, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "METHYLPREDNISOLONE NA SUC (PF) 40 MG/ML IV SYRINGE|DISCARDED DRUG NOT ADMINISTERED", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00009003928_4", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.16, "maximum": 10.77, "gross_charge": 11.46, "discounted_cash": 6.3, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.65, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.16, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.17, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.71, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.33, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.5, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.86, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", 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"standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.16, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "METHYLPREDNISOLONE SODIUM SUCC 1000 MG IJ SOLR", "drug_information": { "unit": "16.000000", "type": "UN" }, "code_information": [ { "code": "00143985101_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.16, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.16, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", 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"payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.22, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.16, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "METHYLPREDNISOLONE SODIUM SUCC 1000 MG IJ SOLR|DISCARDED DRUG NOT ADMINISTERED", "drug_information": { "unit": "16.000000", "type": "UN" }, "code_information": [ { "code": "00143985101", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.16, "maximum": 17.75, "gross_charge": 18.88, "discounted_cash": 10.38, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.95, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.16, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.1, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.99, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.49, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.06, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.31, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.29, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.75, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.61, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.32, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.05, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.16, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.65, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.84, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.75, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.78, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.22, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.01, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.16, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.61, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.95, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.16, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "METHYLPREDNISOLONE SODIUM SUCC 2000 MG IJ SOLR", "drug_information": { "unit": "30.600000", "type": "UN" }, "code_information": [ { "code": "00009085001", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.16, "maximum": 260.06, "gross_charge": 276.66, "discounted_cash": 152.16, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 160.46, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.16, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 221.33, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 234.33, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 80.51, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 132.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 165.72, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 165.44, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 260.06, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 243.46, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 77.96, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 235.16, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 207.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 97.47, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 188.13, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 260.06, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 216.62, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.22, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 219.94, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 207.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 243.46, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 160.46, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.16, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "METHYLPREDNISOLONE SODIUM SUCC 500 MG IJ SOLR", "drug_information": { "unit": "8.000000", "type": "UN" }, "code_information": [ { "code": "43598012811_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.16, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.16, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.22, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.16, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "METHYLPREDNISOLONE SODIUM SUCC 500 MG IJ SOLR|DISCARDED DRUG NOT ADMINISTERED", "drug_information": { "unit": "8.000000", "type": "UN" }, "code_information": [ { "code": "43598012811", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.16, "maximum": 29.52, "gross_charge": 31.4, "discounted_cash": 17.27, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.21, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.16, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.12, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.6, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.14, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.07, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.81, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.63, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.85, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.69, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.55, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.06, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.35, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.59, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.22, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.96, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.55, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.63, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.21, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.16, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "METOCLOPRAMIDE 1 MG/1 ML ORAL SOLUTION (NICU)", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "0121157610", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "METOCLOPRAMIDE HCL 10 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687063101", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "METOCLOPRAMIDE HCL 10 MG/10ML PO SOLN", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "00121157610", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.75, "maximum": 5.85, "gross_charge": 6.22, "discounted_cash": 3.42, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.61, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.98, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.27, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.81, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.99, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.73, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.72, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.85, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.47, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.75, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.29, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.67, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.19, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.23, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.85, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.87, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.94, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.67, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.47, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.61, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "METOCLOPRAMIDE HCL 5 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687062001", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": 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"plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "METOCLOPRAMIDE HCL 5 MG/5ML PO SOLN", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "1785657602", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "METOCLOPRAMIDE HCL 5 MG/ML IJ SOLN", "drug_information": { "unit": "2.000000", "type": "UN" }, "code_information": [ { "code": "23155024041", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "METOCLOPRAMIDE HCL 5 MG/ML IJ SOLN (NICU)", "drug_information": { "unit": "2.000000", "type": "UN" }, "code_information": [ { "code": "00409341401", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "METOLAZONE 10 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "76385013801", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "METOLAZONE 2.5 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687062401", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "METOLAZONE 2MG/ML SUSPENSION", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "P0378617400", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "METOLAZONE 5 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687063501", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.28, "maximum": 4.26, "gross_charge": 4.53, "discounted_cash": 2.49, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.63, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.47, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.62, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.84, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.32, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.17, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.71, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.71, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.26, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.99, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.28, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.85, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.6, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.08, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.26, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.55, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.47, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.6, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.99, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.63, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.47, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "METOPROLOL SUCCINATE ER 100 MG PO TB24", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00904632461", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", 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"additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "METOPROLOL SUCCINATE ER 200 MG PO TB24", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "50268054315", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": 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total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "METOPROLOL SUCCINATE ER 25 MG PO TB24", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": 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"standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "METOPROLOL SUCCINATE ER 50 MG PO TB24", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687040201", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "METOPROLOL TARTRATE 10 MG/ML ORAL SUSPENSION (PTL)", "drug_information": { "unit": "0.630000", "type": "UN" }, "code_information": [ { "code": "08252000185", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "METOPROLOL TARTRATE 100 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "62584026711", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "METOPROLOL TARTRATE 12.5 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "0378001801", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "METOPROLOL TARTRATE 25 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "62584026501", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "METOPROLOL TARTRATE 5 MG/5ML IV SOLN", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "72611074010", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 1158.0, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.72, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "METOPROLOL TARTRATE 50 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "51079080120", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "METRONIDAZOLE 0.75 % EX CREA", "drug_information": { "unit": "45.000000", "type": "GR" }, "code_information": [ { "code": "00168032346", "type": "NDC" } ], "standard_charges": [ { "minimum": 42.38, "maximum": 141.38, "gross_charge": 150.4, "discounted_cash": 82.72, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.23, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.12, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 120.32, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 127.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.77, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 72.19, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 90.09, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 89.94, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 141.38, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 132.35, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.38, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 127.84, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 112.8, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.99, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 102.27, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 141.38, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 117.76, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.12, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 119.57, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 112.8, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 132.35, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.23, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.12, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "METRONIDAZOLE 0.75 % EX GEL", "drug_information": { "unit": "45.000000", "type": "GR" }, "code_information": [ { "code": "51672411606", "type": "NDC" } ], "standard_charges": [ { "minimum": 9.06, "maximum": 30.22, "gross_charge": 32.15, "discounted_cash": 17.68, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.65, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.55, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.72, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.23, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.36, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.43, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.26, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.23, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.22, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.29, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.06, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.33, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.11, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.33, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.86, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.22, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.17, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.55, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.56, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.11, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.29, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.65, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.55, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "METRONIDAZOLE 0.75 % VA GEL", "drug_information": { "unit": "70.000000", "type": "GR" }, "code_information": [ { "code": "45802013970", "type": "NDC" } ], "standard_charges": [ { "minimum": 81.27, "maximum": 271.08, "gross_charge": 288.38, "discounted_cash": 158.61, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 167.26, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 157.46, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 230.7, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 244.26, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 83.92, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 138.42, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 172.74, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 172.45, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 271.08, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 253.77, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 81.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 245.12, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 216.29, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 101.6, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 196.1, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 271.08, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 225.8, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 157.46, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 229.26, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 216.29, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 253.77, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 167.26, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 157.46, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "METRONIDAZOLE 1 % EX GEL", "drug_information": { "unit": "60.000000", "type": "GR" }, "code_information": [ { "code": "51672421503", "type": "NDC" } ], "standard_charges": [ { "minimum": 35.52, "maximum": 118.49, "gross_charge": 126.05, "discounted_cash": 69.33, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 73.11, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 68.82, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 100.84, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 106.76, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.68, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.5, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.5, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.38, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 118.49, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 110.92, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.52, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 107.14, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 94.54, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 44.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 85.71, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 118.49, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 98.7, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 68.82, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 100.21, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 94.54, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 110.92, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 73.11, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 68.82, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "METRONIDAZOLE 250 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687052601", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "METRONIDAZOLE 5 MG/ML IVPB FROM RTU (PEDS)", "drug_information": { "unit": "100.000000", "type": "UN" }, "code_information": [ { "code": "00409015224_5", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "METRONIDAZOLE 5 MG/ML IVPB FROM RTU (PEDS)|DISCARDED DRUG NOT ADMINISTERED", "drug_information": { "unit": "100.000000", "type": "UN" }, "code_information": [ { "code": "00409015224_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.01, "maximum": 3.37, "gross_charge": 3.58, "discounted_cash": 1.97, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.08, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.95, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.86, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.03, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.04, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.72, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.14, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.14, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.37, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.15, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.01, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.04, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.69, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.26, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.43, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.37, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.8, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.95, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.85, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.69, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.15, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.08, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.95, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "METRONIDAZOLE 5 MG/ML SYR FROM RTU (NICU)", "drug_information": { "unit": "100.000000", "type": "UN" }, "code_information": [ { "code": "00409015224_6", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "METRONIDAZOLE 5 MG/ML SYR FROM RTU (NICU)|DISCARDED DRUG NOT ADMINISTERED", "drug_information": { "unit": "100.000000", "type": "UN" }, "code_information": [ { "code": "00409015224_3", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.01, "maximum": 3.37, "gross_charge": 3.58, "discounted_cash": 1.97, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.08, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.95, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.86, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.03, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.04, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.72, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.14, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.14, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.37, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.15, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.01, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.04, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.69, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.26, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.43, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.37, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.8, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.95, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.85, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.69, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.15, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.08, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.95, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "METRONIDAZOLE 5 MG/ML SYR FROM RTU (PEDS)", "drug_information": { "unit": "100.000000", "type": "UN" }, "code_information": [ { "code": "00409015224_7", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "METRONIDAZOLE 5 MG/ML SYR FROM RTU (PEDS)|DISCARDED DRUG NOT ADMINISTERED", "drug_information": { "unit": "100.000000", "type": "UN" }, "code_information": [ { "code": "00409015224_4", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.01, "maximum": 3.37, "gross_charge": 3.58, "discounted_cash": 1.97, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.08, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.95, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.86, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.03, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.04, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.72, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.14, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.14, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.37, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.15, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.01, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.04, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.69, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.26, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.43, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.37, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.8, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.95, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.85, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.69, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.15, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.08, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.95, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "METRONIDAZOLE 500 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687055001", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "METRONIDAZOLE 500 MG/100ML IV SOLN", "drug_information": { "unit": "100.000000", "type": "UN" }, "code_information": [ { "code": "00409015224_8", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "METRONIDAZOLE 500 MG/100ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED", "drug_information": { "unit": "100.000000", "type": "UN" }, "code_information": [ { "code": "00409015224", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.4, "maximum": 1.34, "gross_charge": 1.43, "discounted_cash": 0.79, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.83, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.78, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.14, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.21, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.42, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.69, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.86, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.86, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.34, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.26, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.4, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.22, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.07, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.5, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.97, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.34, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.12, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.78, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.14, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.07, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.26, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.83, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.78, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "METRONIDAZOLE 500 MG/5ML PO SUSP", "drug_information": { "unit": "200.000000", "type": "UN" }, "code_information": [ { "code": "81033006620", "type": "NDC" } ], "standard_charges": [ { "minimum": 149.95, "maximum": 500.17, "gross_charge": 532.1, "discounted_cash": 292.66, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 308.62, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 290.53, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 425.68, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 450.69, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 154.84, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 255.41, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 318.73, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 318.2, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 500.17, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 468.25, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 149.95, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 452.29, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 399.08, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 187.46, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 361.83, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 500.17, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 416.63, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 290.53, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 423.02, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 399.08, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 468.25, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 308.62, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 290.53, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "METRONIDAZOLE 5MG/ML IVPB", "drug_information": { "unit": "100.000000", "type": "UN" }, "code_information": [ { "code": "00264553532_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "METRONIDAZOLE 5MG/ML IVPB|DISCARDED DRUG NOT ADMINISTERED", "drug_information": { "unit": "100.000000", "type": "UN" }, "code_information": [ { "code": "00264553532", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.83, "maximum": 2.75, "gross_charge": 2.93, "discounted_cash": 1.61, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.7, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.6, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.34, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.48, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.85, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.76, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.75, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.75, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.58, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.83, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.49, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.2, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.03, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.99, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.75, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.29, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.6, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.33, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.2, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.58, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.7, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.6, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "METYRAPONE 250 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "76336045518", "type": "NDC" } ], "standard_charges": [ { "minimum": 20.64, "maximum": 68.86, "gross_charge": 73.26, "discounted_cash": 40.29, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.49, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.0, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 58.61, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 62.05, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.32, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.16, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.88, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.81, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 68.86, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 64.47, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.64, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 62.27, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.95, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.81, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.82, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 68.86, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 57.36, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.0, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 58.24, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.95, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 64.47, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.49, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.0, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MEXILETINE 10MG/ML SUSPENSION", "drug_information": { "unit": "15.000000", "type": "UN" }, "code_information": [ { "code": "P0093874001", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MEXILETINE HCL 150 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687077821", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MEXILETINE HCL 200 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "1013573101", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MEXILETINE HCL 250 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00527410937", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MG PLUS PROTEIN 133 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "R1720443440", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MICAFUNGIN 100 MG/100 ML RTU", "drug_information": { "unit": "100.000000", "type": "UN" }, "code_information": [ { "code": "00338905312", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MICAFUNGIN 150 MG/150 ML RTU", "drug_information": { "unit": "150.000000", "type": "UN" }, "code_information": [ { "code": "00338905510", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MICAFUNGIN SODIUM 100 MG IV SOLR", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "25021019111", "type": "NDC" } ], "standard_charges": [ { "minimum": 15.28, "maximum": 50.98, "gross_charge": 54.23, "discounted_cash": 29.83, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.45, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.61, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.38, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.93, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.78, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.03, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.48, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.43, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.98, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.72, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.28, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.1, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.67, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.11, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.88, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.98, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.46, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.61, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.11, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.67, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.72, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.45, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.61, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MICAFUNGIN SODIUM 50 MG IV SOLR", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "00469325010", "type": "NDC" } ], "standard_charges": [ { "minimum": 71.6, "maximum": 238.83, "gross_charge": 254.07, "discounted_cash": 139.74, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 147.36, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 138.72, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 203.26, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 215.2, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 73.93, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 121.95, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 152.19, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 151.93, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 238.83, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 223.58, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 71.6, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 215.96, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 190.55, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 89.51, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 172.77, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 238.83, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 198.94, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 138.72, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 201.99, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 190.55, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 223.58, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 147.36, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 138.72, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MICAFUNGIN SODIUM-NACL 50-0.9 MG/50ML-% IV SOLN", "drug_information": { "unit": "50.000000", "type": "UN" }, "code_information": [ { "code": "00338905112", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MICONAZOLE NITRATE 100 MG VA SUPP", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "61269073607", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MICONAZOLE NITRATE 2 % EX CREA", "drug_information": { "unit": "30.000000", "type": "GR" }, "code_information": [ { "code": "51672200102", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.76, "maximum": 9.21, "gross_charge": 9.8, "discounted_cash": 5.39, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.68, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.35, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.84, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.3, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.85, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.7, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.87, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.86, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.21, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.62, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.76, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.33, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.35, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.45, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.66, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.21, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.67, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.35, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.79, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.35, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.62, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.68, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.35, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MICONAZOLE NITRATE 2 % EX POWD", "drug_information": { "unit": "43.000000", "type": "GR" }, "code_information": [ { "code": "00316022515", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.05, "maximum": 6.84, "gross_charge": 7.28, "discounted_cash": 4.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.22, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.97, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.82, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.12, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.49, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.36, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.35, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.84, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.41, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.05, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.19, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.46, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.56, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.95, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.84, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.7, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.97, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.79, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.46, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.41, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.22, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.97, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MICONAZOLE NITRATE 2 % VA CREA", "drug_information": { "unit": "45.000000", "type": "GR" }, "code_information": [ { "code": "00904773445", "type": "NDC" } ], "standard_charges": [ { "minimum": 3.24, "maximum": 10.79, "gross_charge": 11.48, "discounted_cash": 6.31, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.66, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.27, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.72, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.34, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.51, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.88, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.87, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.79, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.1, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.24, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.76, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.61, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.04, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.81, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.79, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.99, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.27, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.13, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.61, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.1, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.66, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.27, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MICONAZOLE NITRATE 200 MG VA SUPP", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00472173803", "type": "NDC" } ], "standard_charges": [ { "minimum": 8.38, "maximum": 27.95, "gross_charge": 29.73, "discounted_cash": 16.35, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.24, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.23, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.78, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.18, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.65, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.27, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.81, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.95, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.16, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.38, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.27, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.3, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.47, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.22, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.95, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.28, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.23, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.64, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.3, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.16, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.24, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.23, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MICROFIBRILLAR COLL HEMOSTAT EX PADS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "53276101009", "type": "NDC" } ], "standard_charges": [ { "minimum": 138.18, "maximum": 1158.0, "gross_charge": 490.35, "discounted_cash": 269.69, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 284.4, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 267.73, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 425.62, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 142.69, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 235.37, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 293.72, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 293.23, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 460.93, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 431.51, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 138.18, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 416.8, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 367.76, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 172.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 333.44, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 460.93, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 383.94, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 267.73, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 389.83, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 367.76, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 431.51, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 284.4, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 267.73, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MICROFIBRILLAR COLL HEMOSTAT EX POWD", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00998101002", "type": "NDC" } ], "standard_charges": [ { "minimum": 281.87, "maximum": 1158.0, "gross_charge": 1000.26, "discounted_cash": 550.14, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 580.15, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 546.14, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 868.23, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 291.08, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 480.12, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 599.16, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 598.16, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 940.24, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 880.23, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 281.87, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 850.22, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 750.2, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 352.39, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 680.18, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 940.24, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 783.2, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 546.14, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 795.21, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 750.2, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 880.23, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 580.15, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 546.14, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MIDAZOLAM 100 MG/100 ML DRIP RTU", "drug_information": { "unit": "100.000000", "type": "UN" }, "code_information": [ { "code": "70092103036", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MIDAZOLAM 100 MG/100 ML DRIP RTU (ADULT TITRATING)", "drug_information": { "unit": "100.000000", "type": "UN" }, "code_information": [ { "code": "70092103036_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MIDAZOLAM 5 MG/0.1ML NA SOLN", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "50474050015", "type": "NDC" } ], "standard_charges": [ { "minimum": 332.13, "maximum": 1107.88, "gross_charge": 1178.6, "discounted_cash": 648.23, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 683.59, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 643.52, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 942.88, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 998.27, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 342.97, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 565.73, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 705.98, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 704.8, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1107.88, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1037.17, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 332.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1001.81, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 883.95, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 415.22, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 801.45, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1107.88, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 922.84, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 643.52, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 936.99, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 883.95, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1037.17, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 683.59, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 643.52, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MIDAZOLAM 50 MG/50 ML DRIP SYRINGE (STRAIGHT)", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "00409230505", "type": "NDC" } ], "standard_charges": [ { "minimum": 12.68, "maximum": 42.3, "gross_charge": 45.0, "discounted_cash": 24.75, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.1, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.12, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.1, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.91, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.3, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.68, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.25, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.85, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.6, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.3, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.24, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.78, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.1, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MIDAZOLAM HCL (PF) 10 MG/2ML IJ SOLN", "drug_information": { "unit": "0.200000", "type": "UN" }, "code_information": [ { "code": "00409230802", "type": "NDC" } ], "standard_charges": [ { "minimum": 12.68, "maximum": 42.3, "gross_charge": 45.0, "discounted_cash": 24.75, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.1, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.12, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.1, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.91, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.3, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.68, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.25, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.85, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.6, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.3, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.24, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.78, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.1, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MIDAZOLAM HCL (PF) 2 MG/2ML IJ SOLN", "drug_information": { "unit": "2.000000", "type": "UN" }, "code_information": [ { "code": "00409230517", "type": "NDC" } ], "standard_charges": [ { "minimum": 12.68, "maximum": 42.3, "gross_charge": 45.0, "discounted_cash": 24.75, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.1, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.12, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.1, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.91, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.3, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.68, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.25, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.85, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.6, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.3, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.24, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.78, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.1, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MIDAZOLAM HCL (PF) 2 MG/2ML IJ SOLN (NICU)", "drug_information": { "unit": "2.000000", "type": "UN" }, "code_information": [ { "code": "00409230517_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 12.68, "maximum": 42.3, "gross_charge": 45.0, "discounted_cash": 24.75, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.1, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.12, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.1, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.91, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.3, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.68, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.25, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.85, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.6, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.3, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.24, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.78, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.1, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MIDAZOLAM HCL (PF) 5 MG/5ML IJ SOLN", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "00409230505_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 12.68, "maximum": 42.3, "gross_charge": 45.0, "discounted_cash": 24.75, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.1, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.12, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.1, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.91, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.3, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.68, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.25, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.85, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.6, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.3, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.24, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.78, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.1, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MIDAZOLAM HCL (PF) 5 MG/ML IJ SOLN", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00409230801", "type": "NDC" } ], "standard_charges": [ { "minimum": 12.68, "maximum": 42.3, "gross_charge": 45.0, "discounted_cash": 24.75, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.1, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.12, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.1, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.91, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.3, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.68, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.25, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.85, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.6, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.3, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.24, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.78, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.1, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MIDAZOLAM HCL 1 MG/ML IN 0.9% SODIUM CHLORIDE 3ML", "drug_information": { "unit": "0.500000", "type": "UN" }, "code_information": [ { "code": "61553035134", "type": "NDC" } ], "standard_charges": [ { "minimum": 12.68, "maximum": 42.3, "gross_charge": 45.0, "discounted_cash": 24.75, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.1, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.12, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.1, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.91, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.3, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.68, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.25, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.85, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.6, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.3, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.24, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.78, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.1, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MIDAZOLAM HCL 1 MG/ML INTRANASAL", "drug_information": { "unit": "6.000000", "type": "UN" }, "code_information": [ { "code": "00409230517_3", "type": "NDC" } ], "standard_charges": [ { "minimum": 12.68, "maximum": 42.3, "gross_charge": 45.0, "discounted_cash": 24.75, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.1, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.12, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.1, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.91, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.3, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.68, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.25, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.85, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.6, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.3, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.24, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.78, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.1, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MIDAZOLAM HCL 10 MG/10ML IJ SOLN", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "00409258705", "type": "NDC" } ], "standard_charges": [ { "minimum": 12.68, "maximum": 42.3, "gross_charge": 45.0, "discounted_cash": 24.75, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.1, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.12, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.1, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.91, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.3, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.68, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.25, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.85, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.6, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.3, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.24, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.78, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.1, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MIDAZOLAM HCL 2 MG/2ML IJ SOLN", "drug_information": { "unit": "2.000000", "type": "UN" }, "code_information": [ { "code": "00641605725", "type": "NDC" } ], "standard_charges": [ { "minimum": 12.68, "maximum": 42.3, "gross_charge": 45.0, "discounted_cash": 24.75, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.1, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.12, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.1, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.91, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.3, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.68, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.25, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.85, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.6, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.3, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.24, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.78, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.1, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MIDAZOLAM HCL 2 MG/ML PO SYRP", "drug_information": { "unit": "2.500000", "type": "UN" }, "code_information": [ { "code": "60687057610", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.45, "maximum": 8.17, "gross_charge": 8.69, "discounted_cash": 4.78, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.04, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.74, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.95, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.36, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.53, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.17, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.21, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.2, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.17, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.65, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.45, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.52, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.06, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.91, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.17, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.8, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.74, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.91, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.52, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.65, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.04, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.74, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MIDAZOLAM HCL 25 MG/5ML IJ SOLN", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "00409259603", "type": "NDC" } ], "standard_charges": [ { "minimum": 12.68, "maximum": 42.3, "gross_charge": 45.0, "discounted_cash": 24.75, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.1, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.12, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.1, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.91, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.3, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.68, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.25, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.85, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.6, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.3, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.24, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.78, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.1, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MIDAZOLAM HCL 5 MG/5ML IJ SOLN", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "00641605910", "type": "NDC" } ], "standard_charges": [ { "minimum": 12.68, "maximum": 42.3, "gross_charge": 45.0, "discounted_cash": 24.75, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.1, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.12, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", 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"additional_payer_notes": "N/A", "standard_charge_dollar": 39.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.68, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.25, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.85, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.6, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.3, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.24, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.78, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.1, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MIDAZOLAM HCL 5 MG/ML INTRANASAL", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00409230801_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 12.68, "maximum": 42.3, "gross_charge": 45.0, "discounted_cash": 24.75, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.1, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.12, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.1, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.91, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.3, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.68, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.25, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.85, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.6, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.3, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.24, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.78, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.1, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MIDAZOLAM HCL 50 MG/10ML IJ SOLN", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "23155060142", "type": "NDC" } ], "standard_charges": [ { "minimum": 12.68, "maximum": 42.3, "gross_charge": 45.0, "discounted_cash": 24.75, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.1, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.12, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.1, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.91, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.3, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.68, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.25, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.85, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.6, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.3, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.24, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.78, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.1, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MIDAZOLAM-SODIUM CHLORIDE 100-0.9 MG/100ML-% (TITRATABLE RATE) IV SOLN", "drug_information": { "unit": "100.000000", "type": "UN" }, "code_information": [ { "code": "00143938010", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MIDAZOLAM-SODIUM CHLORIDE 100-0.9 MG/100ML-% IV SOLN (FIXED RATE)", "drug_information": { "unit": "100.000000", "type": "UN" }, "code_information": [ { "code": "00143938010_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MIDODRINE HCL 10 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "4229156290", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MIDODRINE HCL 2.5 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687038701", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MIDODRINE HCL 5 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "50268056215", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MIDOSTAURIN 25 MG PO CAPS", "drug_information": { "unit": "2.000000", "type": "UN" }, "code_information": [ { "code": "00078069899", "type": "NDC" } ], "standard_charges": [ { "minimum": 379.4, "maximum": 1265.58, "gross_charge": 1346.36, "discounted_cash": 740.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 780.89, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 735.11, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1077.09, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1140.37, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 391.79, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 646.25, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 806.47, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 805.12, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1265.58, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1184.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 379.4, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1144.41, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1009.77, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 474.32, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 915.52, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1265.58, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1054.2, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 735.11, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1070.36, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1009.77, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1184.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 780.89, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 735.11, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MIFEPRISTONE 200 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "64875000101", "type": "NDC" } ], "standard_charges": [ { "minimum": 30.29, "maximum": 101.05, "gross_charge": 107.5, "discounted_cash": 59.13, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 62.35, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 58.7, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 91.05, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.28, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 51.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 64.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 64.29, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 101.05, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 94.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.29, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 91.38, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 80.63, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.87, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 73.1, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 101.05, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 84.17, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 58.7, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 85.46, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 80.63, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 94.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 62.35, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 58.7, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MILNACIPRAN HCL 25 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00456152560", "type": "NDC" } ], "standard_charges": [ { "minimum": 5.19, "maximum": 17.3, "gross_charge": 18.4, "discounted_cash": 10.12, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.67, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.05, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.72, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.58, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.35, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.83, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.02, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.0, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.3, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.19, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.19, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.64, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.8, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.48, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.51, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.3, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.41, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.05, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.63, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.8, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.19, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.67, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.05, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MILNACIPRAN HCL 50 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00456155060", "type": "NDC" } ], "standard_charges": [ { "minimum": 5.19, "maximum": 17.3, "gross_charge": 18.4, "discounted_cash": 10.12, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.67, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.05, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.72, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.58, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.35, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.83, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.02, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.0, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.3, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.19, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.19, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.64, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.8, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.48, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.51, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.3, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.41, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.05, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.63, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.8, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.19, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.67, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.05, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MILRINONE 20 MG/100 ML D5W RTU", "drug_information": { "unit": "100.000000", "type": "UN" }, "code_information": [ { "code": "25021031382", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MILRINONE LACTATE 10 MG/10ML IV SOLN", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "63323061710", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MILRINONE LACTATE 20 MG/20ML IV SOLN", "drug_information": { "unit": "20.000000", "type": "UN" }, "code_information": [ { "code": "00409021202", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MINERAL OIL LIGHT OIL", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "63323025410", "type": "NDC" } ], "standard_charges": [ { "minimum": 12.74, "maximum": 42.51, "gross_charge": 45.22, "discounted_cash": 24.87, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.23, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.69, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.3, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.71, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.09, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.04, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.51, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.79, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.74, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.44, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.92, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.93, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.75, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.51, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.41, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.69, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.95, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.92, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.79, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.23, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.69, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MINERAL OIL PO OIL", "drug_information": { "unit": "30.000000", "type": "UN" }, "code_information": [ { "code": "48433020230", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MINERAL OIL RE ENEM", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00132030140", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.27, "maximum": 4.23, "gross_charge": 4.5, "discounted_cash": 2.48, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.61, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.46, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.6, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.81, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.31, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.16, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.7, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.69, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.23, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.96, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.83, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.38, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.59, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.06, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.23, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.46, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.58, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.38, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.96, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.61, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.46, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MINERAL OIL STERILE 10 ML CUP (BULK CHARGE)", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "63323025410_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 12.74, "maximum": 42.51, "gross_charge": 45.22, "discounted_cash": 24.87, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.23, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.69, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.3, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.71, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.09, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.04, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.51, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.79, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.74, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.44, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.92, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.93, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.75, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.51, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.41, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.69, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.95, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.92, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.79, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.23, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.69, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MINOCYCLINE 10MG/ML SUSPENSION", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "08252000416", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MINOCYCLINE HCL 100 MG IV SOLR", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "70842016010", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.41, "maximum": 943.38, "gross_charge": 1003.6, "discounted_cash": 551.98, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 582.09, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 802.88, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 850.05, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 292.05, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 481.73, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 601.16, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 600.15, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 943.38, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 883.17, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 282.81, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 853.06, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 752.7, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 353.57, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 682.45, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 943.38, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 785.82, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.91, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 797.86, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 752.7, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 883.17, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 582.09, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "MINOCYCLINE HCL 100 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "65862021150", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MINOCYCLINE HCL 100 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "59651033950", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MINOCYCLINE HCL 50 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "55111063701", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.45, "maximum": 4.82, "gross_charge": 5.13, "discounted_cash": 2.82, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.98, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.8, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.1, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.35, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.49, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.46, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.07, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.07, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.82, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.51, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.45, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.36, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.85, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.81, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.49, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.82, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.02, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.8, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.08, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.85, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.51, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.98, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.8, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MINOXIDIL 10 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68084020501", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MINOXIDIL 2.5 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68084020401", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MIRABEGRON ER 25 MG PO TB24", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68180015106", "type": "NDC" } ], "standard_charges": [ { "minimum": 7.27, "maximum": 24.25, "gross_charge": 25.8, "discounted_cash": 14.19, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.96, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.64, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.85, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.51, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.38, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.45, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.43, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.25, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.7, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.93, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.35, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.54, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.25, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.2, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.51, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.35, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.7, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.96, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MIRABEGRON ER 50 MG PO TB24", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68180015206", "type": "NDC" } ], "standard_charges": [ { "minimum": 5.55, "maximum": 18.5, "gross_charge": 19.68, "discounted_cash": 10.82, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.41, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.75, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.74, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.67, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.73, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.45, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.79, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.77, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.5, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.32, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.55, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.73, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.76, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.93, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.38, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.5, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.41, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.75, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.65, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.76, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.32, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.41, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.75, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MIRABEGRON ER 8 MG/ML PO SRER", "drug_information": { "unit": "3.000000", "type": "UN" }, "code_information": [ { "code": "00469502099", "type": "NDC" } ], "standard_charges": [ { "minimum": 4.42, "maximum": 14.75, "gross_charge": 15.69, "discounted_cash": 8.63, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.1, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.55, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.29, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.57, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.53, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.38, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.75, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.81, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.42, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.34, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.77, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.53, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.67, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.75, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.29, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.47, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.77, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.81, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.1, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MIRTAZAPINE 15 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68084011901", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MIRTAZAPINE 15 MG PO TBDP", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "57237001106", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MIRTAZAPINE 30 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68084012001", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MIRTAZAPINE 30 MG PO TBDP", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "65862002206", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MIRTAZAPINE 45 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "51079008820", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MIRTAZAPINE 7.5 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687058421", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MIRVETUXIMAB SORAVTANSINE-GYNX 100 MG/20ML IV SOLN", "drug_information": { "unit": "20.000000", "type": "UN" }, "code_information": [ { "code": "72903085301", "type": "NDC" } ], "standard_charges": [ { "minimum": 36.45, "maximum": 18293.76, "gross_charge": 19461.45, "discounted_cash": 10703.8, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 11287.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.45, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15569.16, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16483.85, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5663.28, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9341.5, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 11657.41, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 11394.0, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 18293.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17126.08, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 5484.24, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16542.23, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14596.09, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 6856.27, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 13233.79, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 18293.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 15238.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.21, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 15189.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14596.09, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17126.08, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 11287.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.45, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "MISOPROSTOL 100 MCG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687073501", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MISOPROSTOL 200 MCG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687074601", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MISOPROSTOL 25 MCG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "0172443049", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MITOMYCIN 0.2 MG/ML TOPICAL SYRINGE (OPH)", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "16729011505_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 23.21, "maximum": 1158.0, "gross_charge": 841.16, "discounted_cash": 462.64, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 487.87, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.21, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 730.13, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 244.78, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 403.76, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 503.85, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 503.01, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 790.69, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 740.22, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 237.04, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 714.99, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 630.87, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 296.34, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 571.99, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 790.69, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 658.63, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.33, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 668.72, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 630.87, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 740.22, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 487.87, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.21, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "MITOMYCIN 0.25 MG/ML TOPICAL SYRINGE (OPH)", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "1672911505", "type": "NDC" } ], "standard_charges": [ { "minimum": 72.99, "maximum": 1158.0, "gross_charge": 259.02, "discounted_cash": 142.46, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 150.23, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 141.42, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 224.83, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.37, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 124.33, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 155.15, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 154.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 243.48, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 227.94, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 72.99, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 220.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 194.27, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 91.25, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 176.13, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 243.48, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 202.81, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 141.42, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 205.92, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 194.27, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 227.94, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 150.23, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 141.42, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MITOMYCIN 0.3 MG/ML TOPICAL SYRINGE (OPH)", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "16729011505_3", "type": "NDC" } ], "standard_charges": [ { "minimum": 23.21, "maximum": 1158.0, "gross_charge": 841.16, "discounted_cash": 462.64, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 487.87, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.21, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 730.13, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 244.78, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 403.76, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 503.85, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 503.01, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 790.69, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 740.22, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 237.04, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 714.99, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 630.87, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 296.34, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 571.99, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 790.69, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 658.63, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.33, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 668.72, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 630.87, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 740.22, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 487.87, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.21, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "MITOMYCIN 0.4 MG/ML TOPICAL SYRINGE (OPH)", "drug_information": { "unit": "2.000000", "type": "UN" }, "code_information": [ { "code": "1672911505_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 126.25, "maximum": 1158.0, "gross_charge": 448.03, "discounted_cash": 246.42, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 259.86, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 244.62, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 388.89, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 130.38, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 215.05, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 268.37, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 267.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 421.15, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 394.27, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 126.25, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 380.83, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 336.02, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 157.84, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 304.66, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 421.15, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 350.81, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 244.62, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 356.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 336.02, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 394.27, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 259.86, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 244.62, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MITOMYCIN 0.5 MG/ML TOPICAL SYRINGE (OPH)", "drug_information": { "unit": "2.000000", "type": "UN" }, "code_information": [ { "code": "08252000081", "type": "NDC" } ], "standard_charges": [ { "minimum": 126.25, "maximum": 1158.0, "gross_charge": 448.03, "discounted_cash": 246.42, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 259.86, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 244.62, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 388.89, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 130.38, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 215.05, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 268.37, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 267.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 421.15, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 394.27, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 126.25, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 380.83, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 336.02, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 157.84, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 304.66, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 421.15, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 350.81, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 244.62, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 356.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 336.02, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 394.27, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 259.86, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 244.62, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MITOMYCIN 2 MCG/0.1 ML INTRAOCULAR SYRINGE", "drug_information": { "unit": "0.100000", "type": "UN" }, "code_information": [ { "code": "08252000086", "type": "NDC" } ], "standard_charges": [ { "minimum": 117.77, "maximum": 1158.0, "gross_charge": 417.91, "discounted_cash": 229.85, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 242.39, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 228.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 362.75, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 121.61, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 200.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 250.33, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 249.91, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 392.84, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 367.76, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 117.77, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 355.22, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 313.43, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 147.23, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 284.18, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 392.84, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 327.22, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 228.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 332.24, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 313.43, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 367.76, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 242.39, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 228.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MITOMYCIN 20 MG IV SOLR", "drug_information": { "unit": "25.000000", "type": "UN" }, "code_information": [ { "code": "25021025150", "type": "NDC" } ], "standard_charges": [ { "minimum": 23.21, "maximum": 149.43, "gross_charge": 158.97, "discounted_cash": 87.43, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 92.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.21, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 127.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 134.65, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.26, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 76.31, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 95.22, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 95.06, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 149.43, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 139.89, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 44.8, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 135.12, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 119.23, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 56.01, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 108.1, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 149.43, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 124.47, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.33, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 126.38, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 119.23, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 139.89, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 92.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.21, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "MITOMYCIN 20 MG IV SOLR FOR CHEMOPERFUSION", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "16729010811", "type": "NDC" } ], "standard_charges": [ { "minimum": 23.21, "maximum": 2152.19, "gross_charge": 2289.56, "discounted_cash": 1259.26, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1327.94, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.21, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1831.65, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1939.26, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 666.26, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1098.99, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1371.45, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 1369.16, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2152.19, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2014.81, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 645.2, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1946.13, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1717.17, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 806.61, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1556.9, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2152.19, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1792.73, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.33, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1820.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1717.17, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2014.81, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1327.94, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.21, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "MITOMYCIN 40 MG IV SOLR", "drug_information": { "unit": "40.000000", "type": "ME" }, "code_information": [ { "code": "16729011638", "type": "NDC" } ], "standard_charges": [ { "minimum": 23.21, "maximum": 3221.48, "gross_charge": 3427.11, "discounted_cash": 1884.91, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1987.72, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.21, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2741.69, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2902.76, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 997.29, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1645.01, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2052.84, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2049.41, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3221.48, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3015.86, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 965.76, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2913.04, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2570.33, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1207.37, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2330.43, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3221.48, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2683.43, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.33, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2724.55, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2570.33, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3015.86, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1987.72, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.21, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "MITOMYCIN 5 MG IV SOLR", "drug_information": { "unit": "5.000000", "type": "ME" }, "code_information": [ { "code": "16729011505", "type": "NDC" } ], "standard_charges": [ { "minimum": 23.21, "maximum": 724.89, "gross_charge": 771.16, "discounted_cash": 424.14, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 447.27, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.21, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 616.93, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 653.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 224.41, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 370.16, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 461.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 461.15, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 724.89, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 678.62, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 217.31, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 655.49, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 578.37, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 271.68, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 524.39, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 724.89, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 603.82, "standard_charge_percentage": 78.0, "methodology": 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58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.21, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "MITOMYCIN 80 (2 X 40) MG UL SOLR", "drug_information": { "unit": "20.000000", "type": "UN" }, "code_information": [ { "code": "72493010303", "type": "NDC" } ], "standard_charges": [ { "minimum": 11394.0, "maximum": 69033.6, "gross_charge": 73440.0, "discounted_cash": 40392.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 42595.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 40098.24, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 58752.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 62203.68, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21371.04, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35251.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 43990.56, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 11394.0, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 69033.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 64627.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 20695.39, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 62424.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 55080.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 25872.91, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 49939.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", 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"HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 64627.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 42595.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 40098.24, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MITOMYCIN CHEMO SYRINGE", "drug_information": { "unit": "40.000000", "type": "UN" }, "code_information": [ { "code": "16729010811_3", "type": "NDC" } ], "standard_charges": [ { "minimum": 23.21, "maximum": 2217.99, "gross_charge": 2359.56, "discounted_cash": 1297.76, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1368.54, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.21, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1887.65, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1998.55, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 686.63, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1132.59, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1413.38, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 1411.02, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2217.99, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2076.41, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 664.92, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2005.63, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1769.67, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 831.27, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1604.5, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2217.99, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1847.54, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.33, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1875.85, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1769.67, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2076.41, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1368.54, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.21, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "MITOMYCIN CHEMO SYRINGE|DISCARDED DRUG NOT ADMINISTERED", "drug_information": { "unit": "40.000000", "type": "UN" }, "code_information": [ { "code": "16729010811_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 23.21, "maximum": 2152.19, "gross_charge": 2289.56, "discounted_cash": 1259.26, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1327.94, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.21, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1831.65, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1939.26, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 666.26, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1098.99, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1371.45, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 1369.16, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2152.19, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2014.81, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 645.2, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1946.13, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1717.17, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 806.61, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1556.9, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2152.19, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1792.73, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.33, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1820.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1717.17, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2014.81, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1327.94, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.21, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "MITOTANE 250 MG/ML ORAL SUSPENSION (SIMPLE)", "drug_information": { "unit": "2.000000", "type": "UN" }, "code_information": [ { "code": "P0015308060", "type": "NDC" } ], "standard_charges": [ { "minimum": 3.07, "maximum": 10.25, "gross_charge": 10.9, "discounted_cash": 6.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.95, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.72, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.23, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.17, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.23, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.53, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.52, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.25, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.59, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.07, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.27, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.18, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.84, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.41, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.25, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.53, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.95, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.67, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.18, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.59, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.95, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MITOTANE 500 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "76336008060", "type": "NDC" } ], "standard_charges": [ { "minimum": 7.14, "maximum": 23.81, "gross_charge": 25.33, "discounted_cash": 13.93, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.69, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.83, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.26, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.45, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.37, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.16, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.17, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.15, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.81, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.29, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.14, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.53, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.92, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.22, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.81, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.83, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.83, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.14, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.29, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.69, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.83, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MITOXANTRONE HCL 20 MG/10ML IV CONC", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "63323013210", "type": "NDC" } ], "standard_charges": [ { "minimum": 29.84, "maximum": 248.36, "gross_charge": 264.21, "discounted_cash": 145.32, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 153.24, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.84, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 211.37, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 223.79, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 76.89, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 126.82, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 158.26, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 158.0, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 248.36, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 232.5, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.45, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 224.58, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 198.16, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.08, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 179.66, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 248.36, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 206.88, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 210.05, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 198.16, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 232.5, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 153.24, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.84, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "MITOXANTRONE HCL 25 MG/12.5ML IV CONC", "drug_information": { "unit": "12.500000", "type": "UN" }, "code_information": [ { "code": "63323013212", "type": "NDC" } ], "standard_charges": [ { "minimum": 29.84, "maximum": 266.63, "gross_charge": 283.65, "discounted_cash": 156.01, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 164.52, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.84, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 226.92, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 240.25, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.54, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 136.15, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 169.91, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 169.62, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 266.63, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 249.61, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 79.93, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 241.1, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 212.74, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 99.93, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 192.88, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 266.63, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 222.1, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 225.5, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 212.74, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 249.61, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 164.52, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.84, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "Mnpj anes sho jt fixj aprats", "code_information": [ { "code": "23700", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1179.66, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 873.82, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 12000.8, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 21775.64, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1179.66, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 21775.64, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Mnpj elbow under anes", "code_information": [ { "code": "24300", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1179.66, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 873.82, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 13179.58, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 23943.92, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1179.66, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 23943.92, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Mnpj of tmj w/anesth", "code_information": [ { "code": "21073", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1091.85, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 808.78, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 22224.21, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 40326.18, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1091.85, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 40326.18, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MODAFINIL 100 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68084062121", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.87, "maximum": 9.56, "gross_charge": 10.17, "discounted_cash": 5.59, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.9, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.55, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.14, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.61, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.96, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.88, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.09, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.08, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.56, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.95, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.87, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.64, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.63, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.58, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.92, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.56, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.96, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.55, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.09, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.63, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.95, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.9, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.55, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MOGAMULIZUMAB-KPKC 20 MG/5ML IV SOLN", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "42747076101", "type": "NDC" } ], "standard_charges": [ { "minimum": 3963.76, "maximum": 13221.91, "gross_charge": 14065.86, "discounted_cash": 7736.22, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 8158.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 7679.96, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11252.69, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11913.78, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4093.17, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6751.61, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 8425.45, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 8411.38, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13221.91, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12377.96, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3963.76, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11955.98, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10549.4, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 4955.4, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 9564.78, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 13221.91, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 11013.57, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7679.96, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 11182.36, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10549.4, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12377.96, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8158.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7679.96, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Mohs 1 stage h/n/hf/g", "code_information": [ { "code": "17311", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 451.2, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 2688.32, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 4878.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 451.2, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 4878.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Mohs 1 stage t/a/l", "code_information": [ { "code": "17313", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 451.2, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 2354.12, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 4271.58, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 451.2, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 4271.58, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MOMETASONE FURO-FORMOTEROL FUM 100-5 MCG/ACT IN AERO", "drug_information": { "unit": "9.000000", "type": "GR" }, "code_information": [ { "code": "78206012702", "type": "NDC" } ], "standard_charges": [ { "minimum": 295.9, "maximum": 987.05, "gross_charge": 1050.05, "discounted_cash": 577.53, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 609.03, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 573.33, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 840.04, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 889.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 305.56, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 504.02, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 628.98, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 627.93, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 987.05, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 924.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 295.9, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 892.54, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 787.54, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 369.93, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 714.03, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 987.05, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 822.19, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 573.33, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 834.79, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 787.54, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 924.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 609.03, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 573.33, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MOMETASONE FUROATE 0.1 % EX CREA", "drug_information": { "unit": "15.000000", "type": "GR" }, "code_information": [ { "code": "00713063415", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.7, "maximum": 9.01, "gross_charge": 9.58, "discounted_cash": 5.27, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.56, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.23, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.66, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.11, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.79, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.74, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.73, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.01, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.43, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.7, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.14, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.19, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.38, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.51, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.01, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.5, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.23, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.62, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.19, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.43, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.56, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.23, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MOMETASONE FUROATE 0.1 % EX OINT", "drug_information": { "unit": "45.000000", "type": "GR" }, "code_information": [ { "code": "45802011942", "type": "NDC" } ], "standard_charges": [ { "minimum": 18.57, "maximum": 61.95, "gross_charge": 65.9, "discounted_cash": 36.25, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.98, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.72, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.82, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.18, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.63, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.47, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.41, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.95, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 57.99, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.57, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 56.02, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.43, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.22, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 44.81, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.95, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 51.6, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.98, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.39, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.43, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 57.99, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.98, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MOMETASONE FUROATE 110 MCG/ACT IN AEPB", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "78206011501", "type": "NDC" } ], "standard_charges": [ { "minimum": 71.21, "maximum": 237.53, "gross_charge": 252.69, "discounted_cash": 138.98, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 146.56, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 137.97, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 202.15, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 214.03, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 73.53, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 121.29, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 151.36, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 151.11, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 237.53, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 222.37, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 71.21, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 214.79, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 189.52, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 89.02, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 171.83, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 237.53, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 197.86, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 137.97, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 200.89, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 189.52, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 222.37, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 146.56, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 137.97, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MOMETASONE FUROATE 1350 MCG NA IMPL", "drug_information": { "unit": "1.350000", "type": "ME" }, "code_information": [ { "code": "10599000301", "type": "NDC" } ], "standard_charges": [ { "minimum": 1246.42, "maximum": 4157.67, "gross_charge": 4423.05, "discounted_cash": 2432.68, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2565.37, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2414.99, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3538.44, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3746.32, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1287.11, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2123.06, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2649.41, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2644.98, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4157.67, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3892.28, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1246.42, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3759.59, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3317.29, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1558.24, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3007.67, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4157.67, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3463.25, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2414.99, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3516.32, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3317.29, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3892.28, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2565.37, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2414.99, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MOMETASONE FUROATE 220 MCG/ACT IN AEPB", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "78206011402", "type": "NDC" } ], "standard_charges": [ { "minimum": 105.28, "maximum": 351.17, "gross_charge": 373.59, "discounted_cash": 205.47, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 216.68, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 203.98, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 298.87, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 316.43, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 108.71, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 179.32, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 223.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 223.41, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 351.17, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 328.76, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 105.28, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 317.55, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 280.19, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 131.62, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 254.04, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 351.17, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 292.52, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 203.98, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 297.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 280.19, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 328.76, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 216.68, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 203.98, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MONSELS FERRIC SUBSULFATE EX SOLN", "drug_information": { "unit": "8.000000", "type": "UN" }, "code_information": [ { "code": "48783011208_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 12.47, "maximum": 1158.0, "gross_charge": 44.25, "discounted_cash": 24.34, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.67, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.16, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.41, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.88, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.24, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.51, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.46, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.94, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.47, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.61, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.19, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.59, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.09, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.65, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.16, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.19, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.94, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.67, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.16, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MONTELUKAST SODIUM 10 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00904680861", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MONTELUKAST SODIUM 4 MG PO CHEW", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "50268057315", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MONTELUKAST SODIUM 4 MG PO PACK", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "27241001531", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.57, "maximum": 5.23, "gross_charge": 5.56, "discounted_cash": 3.06, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.22, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.04, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.71, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.62, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.67, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.33, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.32, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.23, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.89, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.57, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.73, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.17, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.96, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.78, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.23, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.35, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.04, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.42, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.17, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.89, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.22, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.04, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MONTELUKAST SODIUM 5 MG PO CHEW", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "50268057415", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MORPHINE (PF) 10 MG/ML INTRATHECAL SYRINGE", "drug_information": { "unit": "20.000000", "type": "UN" }, "code_information": [ { "code": "66794016002_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 139.91, "maximum": 466.69, "gross_charge": 496.48, "discounted_cash": 273.06, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 287.96, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 271.08, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 397.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 420.52, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 144.48, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 238.31, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 297.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 296.9, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 466.69, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 436.9, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 139.91, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 422.01, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 372.36, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 174.91, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 337.61, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 466.69, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 388.74, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 271.08, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 394.7, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 372.36, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 436.9, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 287.96, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 271.08, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MORPHINE (PF) 25 MG/ML INTRATHECAL SYRINGE", "drug_information": { "unit": "20.000000", "type": "UN" }, "code_information": [ { "code": "66794016202_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 224.08, "maximum": 747.47, "gross_charge": 795.18, "discounted_cash": 437.35, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 461.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 434.17, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 636.14, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 673.52, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 231.4, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 381.69, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 476.31, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 475.52, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 747.47, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 699.76, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 224.08, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 675.9, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 596.39, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 280.14, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 540.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 747.47, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 622.63, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 434.17, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 632.17, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 596.39, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 699.76, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 461.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 434.17, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MORPHINE 0.2% TOPICAL GEL", "drug_information": { "unit": "30.000000", "type": "GR" }, "code_information": [ { "code": "R0406152130", "type": "NDC" } ], "standard_charges": [ { "minimum": 13.79, "maximum": 46.01, "gross_charge": 48.95, "discounted_cash": 26.92, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.39, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.73, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.16, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.46, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.24, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.5, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.32, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.27, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.01, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.08, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.79, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.61, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.71, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.25, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.29, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.01, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.33, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.73, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.92, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.71, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.08, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.39, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.73, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MORPHINE 100 MG/100 ML DRIP RTU (FIXED RATE)", "drug_information": { "unit": "100.000000", "type": "UN" }, "code_information": [ { "code": "70092138036", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MORPHINE 100 MG/100 ML DRIP RTU (TITRATABLE RATE)", "drug_information": { "unit": "100.000000", "type": "UN" }, "code_information": [ { "code": "70092138036_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MORPHINE 50 MG/50 ML DRIP SYRINGE (PEDS)(MULTI GPI)", "drug_information": { "unit": "50.000000", "type": "UN" }, "code_information": [ { "code": "70092152350", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MORPHINE 50 MG/50 ML PCA SYRINGE", "drug_information": { "unit": "50.000000", "type": "UN" }, "code_information": [ { "code": "70092152350_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MORPHINE 50 MG/50 ML PCA SYRINGE (503B)(MULTI GPI)", "drug_information": { "unit": "50.000000", "type": "UN" }, "code_information": [ { "code": "70092152350_3", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MORPHINE SULF MICROINFUSION PF 200 MG/20ML (10 MG/ML) IJ SOLN", "drug_information": { "unit": "20.000000", "type": "UN" }, "code_information": [ { "code": "66794016002", "type": "NDC" } ], "standard_charges": [ { "minimum": 120.18, "maximum": 400.89, "gross_charge": 426.48, "discounted_cash": 234.56, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 247.36, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 232.86, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 341.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 361.23, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 124.11, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 204.71, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 255.46, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 255.04, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 400.89, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 375.3, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 120.18, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 362.51, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 319.86, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 150.25, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 290.01, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 400.89, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 333.93, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 232.86, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 339.05, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 319.86, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 375.3, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 247.36, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 232.86, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MORPHINE SULF MICROINFUSION PF 500 MG/20ML (25 MG/ML) IJ SOLN", "drug_information": { "unit": "20.000000", "type": "UN" }, "code_information": [ { "code": "66794016202", "type": "NDC" } ], "standard_charges": [ { "minimum": 204.36, "maximum": 681.67, "gross_charge": 725.18, "discounted_cash": 398.85, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 420.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 395.95, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 580.14, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 614.23, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 211.03, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 348.09, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 434.38, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 433.66, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 681.67, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 638.16, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 204.36, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 616.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 543.89, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 255.48, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 493.12, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 681.67, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 567.82, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 395.95, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 576.52, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 543.89, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 638.16, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 420.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 395.95, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MORPHINE SULFATE (CONCENTRATE) 20 MG/ML PO SOLN", "drug_information": { "unit": "0.500000", "type": "UN" }, "code_information": [ { "code": "00406800330", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.25, "maximum": 7.52, "gross_charge": 8.0, "discounted_cash": 4.4, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.4, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.78, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.33, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.84, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.79, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.25, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.8, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.82, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.44, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.26, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.36, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MORPHINE SULFATE (PF) 0.5 MG/ML IJ SOLN", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "00409381412", "type": "NDC" } ], "standard_charges": [ { "minimum": 12.68, "maximum": 42.3, "gross_charge": 45.0, "discounted_cash": 24.75, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.1, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.12, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.1, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.91, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.3, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.68, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.25, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.85, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.6, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.3, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.24, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.78, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.1, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MORPHINE SULFATE (PF) 0.5 MG/ML INJ SOLN 10 ML VIAL (BULK CHARGE)", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "00409381412_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 12.68, "maximum": 42.3, "gross_charge": 45.0, "discounted_cash": 24.75, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.1, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.12, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.1, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.91, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.3, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.68, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.25, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.85, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.6, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.3, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.24, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.78, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.1, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MORPHINE SULFATE (PF) 1 MG/ML IJ SOLN", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "00409381512", "type": "NDC" } ], "standard_charges": [ { "minimum": 12.68, "maximum": 42.3, "gross_charge": 45.0, "discounted_cash": 24.75, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.1, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.12, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.1, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.91, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.3, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.68, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.25, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.85, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.6, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.3, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.24, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.78, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.1, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MORPHINE SULFATE (PF) 10 MG/ML IJ SOLN", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "63323045101", "type": "NDC" } ], "standard_charges": [ { "minimum": 12.68, "maximum": 42.3, "gross_charge": 45.0, "discounted_cash": 24.75, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.1, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.12, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.1, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.91, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.3, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.68, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.25, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.85, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.6, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.3, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.24, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.78, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.1, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MORPHINE SULFATE (PF) 2 MG/ML IV SOLN", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00409189001", "type": "NDC" } ], "standard_charges": [ { "minimum": 12.68, "maximum": 42.3, "gross_charge": 45.0, "discounted_cash": 24.75, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.1, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.12, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.1, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.91, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.3, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.68, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.25, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.85, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.6, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.3, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.24, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.78, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.1, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MORPHINE SULFATE 1 MG/ML IV SOLN", "drug_information": { "unit": "50.000000", "type": "UN" }, "code_information": [ { "code": "73177010505", "type": "NDC" } ], "standard_charges": [ { "minimum": 12.68, "maximum": 42.3, "gross_charge": 45.0, "discounted_cash": 24.75, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.1, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.12, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.1, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.91, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.3, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.68, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.25, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.85, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.6, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.3, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.24, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.78, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.1, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MORPHINE SULFATE 10 MG/5ML PO SOLN", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "68094000162", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.25, "maximum": 7.52, "gross_charge": 8.0, "discounted_cash": 4.4, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.4, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.78, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.33, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.84, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.79, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.25, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.8, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.82, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.44, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.26, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.36, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MORPHINE SULFATE 10 MG/ML IV SOLN", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00641612725", "type": "NDC" } ], "standard_charges": [ { "minimum": 12.68, "maximum": 42.3, "gross_charge": 45.0, "discounted_cash": 24.75, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.1, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.12, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.1, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.91, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.3, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.68, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.25, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.85, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.6, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.3, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.24, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.78, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.1, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MORPHINE SULFATE 15 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00054023524", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.25, "maximum": 7.52, "gross_charge": 8.0, "discounted_cash": 4.4, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.4, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.78, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.33, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.84, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.79, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.25, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.8, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.82, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.44, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.26, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.36, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MORPHINE SULFATE 30 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00054023624", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.25, "maximum": 7.52, "gross_charge": 8.0, "discounted_cash": 4.4, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.4, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.78, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.33, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.84, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.79, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.25, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.8, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.82, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.44, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.26, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.36, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MORPHINE SULFATE 4 MG/ML IV/IJ SOLN (MULTI-GPI)", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00641612525", "type": "NDC" } ], "standard_charges": [ { "minimum": 12.68, "maximum": 42.3, "gross_charge": 45.0, "discounted_cash": 24.75, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.1, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.12, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.1, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.91, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.3, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.68, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.25, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.85, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.6, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.3, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.24, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.78, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.1, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MORPHINE SULFATE 60MG-BACLOFEN 1.8MG-BUPIVACAINE 90 MG IN 12 ML INTRATHECAL SYR", "drug_information": { "unit": "12.000000", "type": "UN" }, "code_information": [ { "code": "08252000052", "type": "NDC" } ], "standard_charges": [ { "minimum": 188.81, "maximum": 1158.0, "gross_charge": 670.0, "discounted_cash": 368.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 388.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 365.82, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 581.56, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 194.97, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 321.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 401.33, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 400.66, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 629.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 589.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 188.81, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 569.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 502.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 236.04, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 455.6, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 629.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 524.61, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 365.82, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 532.65, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 502.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 589.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 388.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 365.82, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MORPHINE SULFATE ER 100 MG PO TBCR", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00406839062", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.25, "maximum": 7.52, "gross_charge": 8.0, "discounted_cash": 4.4, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.4, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.78, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.33, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.84, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.79, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.25, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.8, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.82, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.44, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.26, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.36, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MORPHINE SULFATE ER 15 MG PO TBCR", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00406831562", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.25, "maximum": 7.52, "gross_charge": 8.0, "discounted_cash": 4.4, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.4, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.78, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.33, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.84, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.79, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.25, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.8, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.82, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.44, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.26, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.36, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MORPHINE SULFATE ER 30 MG PO TBCR", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00406833062", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.25, "maximum": 7.52, "gross_charge": 8.0, "discounted_cash": 4.4, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.4, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.78, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.33, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.84, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.79, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.25, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.8, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.82, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.44, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.26, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.36, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MORPHINE SULFATE ER 60 MG PO TBCR", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00406838062", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.25, "maximum": 7.52, "gross_charge": 8.0, "discounted_cash": 4.4, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.4, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.78, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.33, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.84, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.79, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.25, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.8, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.82, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.44, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.26, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.36, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MORPHINE SULFATE POWD", "drug_information": { "unit": "25.000000", "type": "GR" }, "code_information": [ { "code": "38779067304", "type": "NDC" } ], "standard_charges": [ { "minimum": 83.69, "maximum": 1158.0, "gross_charge": 297.0, "discounted_cash": 163.35, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 172.26, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 162.16, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 257.8, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.43, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 142.56, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 177.9, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 177.61, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 279.18, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 261.36, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 83.69, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 252.45, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 222.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 104.63, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 201.96, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 279.18, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 232.55, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 162.16, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 236.12, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 222.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 261.36, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 172.26, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 162.16, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MORPHINE SULFATE-NACL 50-0.9 MG/50ML-% IV SOLN", "drug_information": { "unit": "50.000000", "type": "UN" }, "code_information": [ { "code": "70092152235", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MORPHINE SULFATE-NACL 50-0.9 MG/50ML-% IV SOLN (ADULT TITRATING)(MULTI GPI)", "drug_information": { "unit": "50.000000", "type": "UN" }, "code_information": [ { "code": "70092152235_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MOSUNETUZUMAB-AXGB 1 MG/ML IV SOLN", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "50242015901", "type": "NDC" } ], "standard_charges": [ { "minimum": 346.97, "maximum": 2301.16, "gross_charge": 2448.04, "discounted_cash": 1346.42, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1419.86, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 346.97, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1958.43, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2073.49, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 712.38, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1175.06, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1466.38, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 1463.93, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2301.16, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2154.28, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 689.86, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2080.83, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1836.03, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 862.44, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1664.67, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2301.16, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1916.82, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 468.4, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1946.19, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1836.03, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2154.28, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1419.86, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 346.97, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "MOSUNETUZUMAB-AXGB 1 MG/ML IV SOLN (MULTI-GPI)", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "50242015901_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 346.97, "maximum": 2301.16, "gross_charge": 2448.04, "discounted_cash": 1346.42, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1419.86, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 346.97, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1958.43, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2073.49, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 712.38, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1175.06, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1466.38, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 1463.93, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2301.16, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2154.28, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 689.86, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2080.83, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1836.03, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 862.44, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1664.67, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2301.16, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1916.82, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 468.4, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1946.19, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1836.03, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2154.28, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1419.86, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 346.97, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "MOSUNETUZUMAB-AXGB 30 MG/30ML IV SOLN", "drug_information": { "unit": "30.000000", "type": "UN" }, "code_information": [ { "code": "50242014201", "type": "NDC" } ], "standard_charges": [ { "minimum": 346.97, "maximum": 51776.47, "gross_charge": 55081.35, "discounted_cash": 30294.74, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 31947.18, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 346.97, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 44065.08, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 46653.9, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16028.67, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 26439.05, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 32993.73, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 11394.0, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 51776.47, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 48471.59, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 15521.92, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 46819.15, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 41311.01, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 19405.16, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37455.32, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue 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charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 48471.59, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31947.18, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 346.97, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "MOXIFLOXACIN 1.6 MG/ML IVPB FROM RTU", "drug_information": { "unit": "250.000000", "type": "UN" }, "code_information": [ { "code": "67457032325_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 47.84, "maximum": 159.58, "gross_charge": 169.77, "discounted_cash": 93.37, "setting": "inpatient", 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"additional_payer_notes": "N/A", "standard_charge_dollar": 149.4, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.84, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 144.3, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 127.33, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.81, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 115.44, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 159.58, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 132.93, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 92.69, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 134.97, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 127.33, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 149.4, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 98.47, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 92.69, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { 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charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 143.8, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.4, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 81.49, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 101.69, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 101.52, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 159.58, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 149.4, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.84, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 144.3, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 127.33, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.81, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 115.44, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 159.58, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 132.93, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 92.69, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 134.97, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 127.33, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 149.4, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 98.47, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 92.69, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MOXIFLOXACIN 400 MG/250 ML RTU", "drug_information": { "unit": "250.000000", "type": "UN" }, "code_information": [ { "code": "67457032325", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MOXIFLOXACIN HCL 0.5 % OP SOLN", "drug_information": { "unit": "3.000000", "type": "UN" }, "code_information": [ { "code": "68180042201", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MOXIFLOXACIN HCL 1 MG/ML IO SOLN", "drug_information": { "unit": "0.800000", "type": "UN" }, "code_information": [ { "code": "71384050908", "type": "NDC" } ], "standard_charges": [ { "minimum": 13.03, "maximum": 43.48, "gross_charge": 46.25, "discounted_cash": 25.44, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.83, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.25, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.46, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.7, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.66, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.48, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.7, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.03, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.31, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.69, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.29, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.45, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.48, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.21, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.25, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.77, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.69, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.7, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.83, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.25, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MOXIFLOXACIN HCL 5 MG/ML IO SOLN", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "71449009742", "type": "NDC" } ], "standard_charges": [ { "minimum": 16.91, "maximum": 1158.0, "gross_charge": 60.0, "discounted_cash": 33.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.76, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.08, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.46, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.94, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.88, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 56.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.91, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 51.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.14, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 56.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.98, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.76, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.7, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.76, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MOXIFLOXACIN HCL-BSS 1 MG/ML IZ SOLN", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "71449009642", "type": "NDC" } ], "standard_charges": [ { "minimum": 15.47, "maximum": 51.59, "gross_charge": 54.88, "discounted_cash": 30.18, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.83, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.96, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.9, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.48, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.97, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.34, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.87, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.82, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 51.59, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 48.29, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.47, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.65, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.16, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.33, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.32, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 51.59, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.97, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.96, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.63, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.16, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 48.29, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.83, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.96, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MTP-101LF 35 ML COLONOSCOPIC ROUTE", "drug_information": { "unit": "35.000000", "type": "UN" }, "code_information": [ { "code": "08252000244", "type": "NDC" } ], "standard_charges": [ { "minimum": 1194.13, "maximum": 3983.25, "gross_charge": 4237.5, "discounted_cash": 2330.63, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2457.75, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2313.68, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3390.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3589.16, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1233.11, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2034.0, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2538.26, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2534.03, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3983.25, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3729.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1194.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3601.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3178.13, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1492.87, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2881.5, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3983.25, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3317.96, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2313.68, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3368.81, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3178.13, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3729.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2457.75, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2313.68, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MTP-101LR 35 ML COLONOSCOPIC ROUTE", "drug_information": { "unit": "35.000000", "type": "UN" }, "code_information": [ { "code": "08252000243", "type": "NDC" } ], "standard_charges": [ { "minimum": 1194.13, "maximum": 3983.25, "gross_charge": 4237.5, "discounted_cash": 2330.63, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2457.75, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2313.68, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3390.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3589.16, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1233.11, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2034.0, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2538.26, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2534.03, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3983.25, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3729.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1194.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3601.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3178.13, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1492.87, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2881.5, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3983.25, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3317.96, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2313.68, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3368.81, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3178.13, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3729.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2457.75, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2313.68, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MULTI-VITAMINS PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00904053961", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MULTIVITAMIN PO LIQD", "drug_information": { "unit": "15.000000", "type": "UN" }, "code_information": [ { "code": "81033050150", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.18, "maximum": 3.94, "gross_charge": 4.19, "discounted_cash": 2.3, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.43, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.29, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.35, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.55, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.22, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.01, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.51, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.51, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.94, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.69, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.18, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.56, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.14, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.48, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.85, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.94, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.28, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.29, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.33, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.14, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.69, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.43, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.29, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MUPIROCIN 2 % EX OINT", "drug_information": { "unit": "22.000000", "type": "GR" }, "code_information": [ { "code": "68462018022", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.9, "maximum": 6.33, "gross_charge": 6.73, "discounted_cash": 3.7, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.9, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.67, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.38, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.7, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.96, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.23, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.03, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.02, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.33, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.92, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.9, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.72, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.05, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.37, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.58, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.33, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.27, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.67, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.35, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.05, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.92, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.9, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.67, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MUPIROCIN 2% EX CREAM 30GM (BULK CHARGE)", "drug_information": { "unit": "30.000000", "type": "GR" }, "code_information": [ { "code": "51672137002", "type": "NDC" } ], "standard_charges": [ { "minimum": 16.33, "maximum": 54.47, "gross_charge": 57.95, "discounted_cash": 31.87, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.61, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.64, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.36, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.08, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.86, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.82, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.71, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.65, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.47, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 51.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.33, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.26, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.46, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.42, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.41, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.47, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.37, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.64, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.07, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.46, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 51.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.61, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.64, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MUPIROCIN CALCIUM 2 % EX CREA", "drug_information": { "unit": "30.000000", "type": "GR" }, "code_information": [ { "code": "51672137002_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 16.33, "maximum": 54.47, "gross_charge": 57.95, "discounted_cash": 31.87, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.61, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.64, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.36, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.08, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.86, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.82, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.71, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.65, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.47, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 51.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.33, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.26, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.46, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.42, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.41, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.47, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.37, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.64, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.07, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.46, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 51.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.61, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.64, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Musc myoq/fscq flp h&n pedcl", "code_information": [ { "code": "15733", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2698.5, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1998.89, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 20094.42, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 36461.66, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2698.5, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 36461.66, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Musc/tdn transfer upr a/e 1", "code_information": [ { "code": "24301", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 5265.64, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3900.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 39618.72, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 71901.25, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5265.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 71901.25, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Muscle biopsy superficial", "code_information": [ { "code": "20200", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1194.28, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 884.65, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 13347.36, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 24219.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1194.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 24219.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Muscle transfer shoulder/arm", "code_information": [ { "code": "23395", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 5265.64, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3900.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 25047.84, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 45457.03, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5265.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 45457.03, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Muscle transfers", "code_information": [ { "code": "23397", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 5265.64, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3900.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 20904.47, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 37931.54, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5265.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 37931.54, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Muscle-skin graft arm", "code_information": [ { "code": "15736", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1348.33, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 998.76, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 9502.62, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 17242.65, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1348.33, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 17242.65, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Muscle-skin graft leg", "code_information": [ { "code": "15738", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2698.5, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1998.89, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 12490.1, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 30547.47, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2698.5, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 30547.47, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Muscle-skin graft trunk", "code_information": [ { "code": "15734", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2698.5, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1998.89, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 27640.81, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 50154.71, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2698.5, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 50154.71, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MYCOPHENOLATE MOFETIL 200 MG/ML PO SUSR", "drug_information": { "unit": "160.000000", "type": "UN" }, "code_information": [ { "code": "1671434501", "type": "NDC" }, { "code": "1671434501_2", "type": "NDC" }, { "code": "69238159502", "type": "NDC" } ], "standard_charges": [ { "minimum": 10.56, "maximum": 35.22, "gross_charge": 37.47, "discounted_cash": 20.61, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.73, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.46, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.98, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.74, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.9, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.99, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.44, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.41, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.22, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.97, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.56, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.85, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.1, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.2, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.48, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.22, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.34, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.46, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.79, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.1, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.97, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.73, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.46, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" }, { "minimum": 10.72, "maximum": 35.76, "gross_charge": 38.04, "discounted_cash": 20.92, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.06, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.77, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.43, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.22, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.07, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.26, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.79, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.75, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.48, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.72, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.33, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.53, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.4, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.87, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.79, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.77, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.24, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.53, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.48, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.06, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.77, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" }, { "minimum": 233.83, "maximum": 779.99, "gross_charge": 829.78, "discounted_cash": 456.38, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 481.27, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 453.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 663.82, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 702.82, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 241.47, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 398.29, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 497.04, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 496.21, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 779.99, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 730.21, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 233.83, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 705.31, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 622.34, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 292.33, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 564.25, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 779.99, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 649.72, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 453.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 659.68, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 622.34, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 730.21, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 481.27, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 453.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MYCOPHENOLATE MOFETIL 250 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687049401", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MYCOPHENOLATE MOFETIL 500 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687043801", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MYCOPHENOLATE MOFETIL HCL 500 MG IV SOLR", "drug_information": { "unit": "30.000000", "type": "UN" }, "code_information": [ { "code": "71288080321", "type": "NDC" } ], "standard_charges": [ { "minimum": 22.44, "maximum": 74.84, "gross_charge": 79.62, "discounted_cash": 43.79, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.18, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.47, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.7, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 67.44, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.17, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.69, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.61, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.84, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 70.07, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.44, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 67.68, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.72, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.05, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.14, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.84, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 62.34, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.47, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.3, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.72, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 70.07, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.18, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.47, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MYCOPHENOLATE SODIUM 180 MG PO TBEC", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68084090721", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.74, "maximum": 5.79, "gross_charge": 6.16, "discounted_cash": 3.39, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.57, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.36, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.93, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.22, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.79, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.96, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.69, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.68, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.79, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.42, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.74, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.24, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.62, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.17, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.19, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.79, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.82, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.36, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.9, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.62, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.42, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.57, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.36, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "MYCOPHENOLATE SODIUM 360 MG PO TBEC", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68084091825", "type": "NDC" } ], "standard_charges": [ { "minimum": 3.55, "maximum": 11.83, "gross_charge": 12.59, "discounted_cash": 6.92, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.3, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.87, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.07, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.66, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.66, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.04, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.54, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.53, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.83, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.08, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.55, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.7, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.44, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.44, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.56, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.83, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.86, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.87, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.01, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.44, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.08, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.3, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.87, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Myelography lumbar injection", "code_information": [ { "code": "62303", "type": "HCPCS" }, { "code": "62305", "type": "HCPCS" }, { "code": "62302", "type": "HCPCS" }, { "code": "62304", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 582.35, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 431.37, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 3759.68, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 6822.01, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 582.35, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 6822.01, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Myomectomy abdom complex", "code_information": [ { "code": "58146", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 28791.82, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 52243.24, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 52243.24, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Myomectomy abdom method", "code_information": [ { "code": "58140", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 22527.49, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 40876.5, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 40876.5, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Myomectomy vag method", "code_information": [ { "code": "58145", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2343.63, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1736.02, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 5748.41, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 10713.2, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2343.63, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 10713.2, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "N block inj celiac pelus", "code_information": [ { "code": "64530", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 656.23, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 486.1, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 7207.1, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 13077.4, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 656.23, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 13077.4, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "N block inj hypogas plxs", "code_information": [ { "code": "64517", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 656.23, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 486.1, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 3070.24, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 5571.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 656.23, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 5571.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "N block lumbar/thoracic", "code_information": [ { "code": "64520", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 656.23, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 486.1, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 2688.32, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 4878.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 656.23, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 4878.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "N block stellate ganglion", "code_information": [ { "code": "64510", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 656.23, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 486.1, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 2499.84, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 4536.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 656.23, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 4536.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "NA CHONDROIT SULF-NA HYALURON 20-15 MG/0.5ML IO SOSY", "drug_information": { "unit": "0.500000", "type": "UN" }, "code_information": [ { "code": "08065183905", "type": "NDC" } ], "standard_charges": [ { "minimum": 58.11, "maximum": 1158.0, "gross_charge": 206.22, "discounted_cash": 113.42, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 119.61, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 112.6, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 179.0, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 98.99, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 123.53, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 123.32, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 193.85, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 181.47, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 58.11, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 175.29, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 154.67, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 72.65, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 140.23, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 193.85, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 161.47, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 112.6, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 163.94, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 154.67, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 181.47, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 119.61, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 112.6, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "NA CHONDROIT SULF-NA HYALURON 40-17 MG/ML IO SOLN", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "08065183710", "type": "NDC" } ], "standard_charges": [ { "minimum": 57.35, "maximum": 1158.0, "gross_charge": 203.52, "discounted_cash": 111.94, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 118.04, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 111.12, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 176.66, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.22, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 97.69, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 121.91, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 121.7, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 191.31, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 179.1, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 57.35, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 172.99, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 152.64, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 71.7, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 138.39, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 191.31, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 159.36, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 111.12, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 161.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 152.64, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 179.1, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 118.04, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 111.12, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "NA CHONDROIT-NA HYALURON 40-30 MG/ML IO SOLN 0.5ML SYR (BULK CHARGE)", "drug_information": { "unit": "0.500000", "type": "UN" }, "code_information": [ { "code": "08065183905_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 58.11, "maximum": 1158.0, "gross_charge": 206.22, "discounted_cash": 113.42, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 119.61, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 112.6, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 179.0, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 98.99, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 123.53, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 123.32, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 193.85, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 181.47, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 58.11, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 175.29, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 154.67, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 72.65, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 140.23, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 193.85, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 161.47, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 112.6, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 163.94, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 154.67, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 181.47, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 119.61, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 112.6, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "NA FERRIC GLUC CPLX IN SUCROSE 12.5 MG/ML IV SOLN", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "00143957010", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "NA SULFATE-K SULFATE-MG SULF 17.5-3.13-1.6 GM/177ML PO SOLN", "drug_information": { "unit": "177.000000", "type": "UN" }, "code_information": [ { "code": "52268001201", "type": "NDC" } ], "standard_charges": [ { "minimum": 36.91, "maximum": 123.12, "gross_charge": 130.98, "discounted_cash": 72.04, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.97, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 71.52, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 104.78, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 110.94, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.12, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 62.87, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 78.46, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 78.33, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 123.12, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 115.26, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.91, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 111.33, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 98.24, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.14, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 89.07, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 123.12, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 102.56, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 71.52, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 104.13, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 98.24, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 115.26, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.97, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 71.52, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "NABUMETONE 500 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "69097096507", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "NADOLOL 20 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687030225", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.25, "maximum": 4.18, "gross_charge": 4.45, "discounted_cash": 2.45, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.58, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.43, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.56, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.77, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.29, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.14, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.67, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.66, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.18, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.92, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.25, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.78, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.34, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.57, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.03, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.18, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.48, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.43, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.54, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.34, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.92, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.58, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.43, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "NADOLOL 40 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687031325", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.5, "maximum": 5.02, "gross_charge": 5.34, "discounted_cash": 2.94, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.1, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.92, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.27, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.52, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.55, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.56, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.19, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.02, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.7, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.5, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.54, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.01, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.88, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.63, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.02, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.18, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.92, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.25, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.01, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.7, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.1, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.92, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "NADOLOL 5MG/ML SUSPENSION", "drug_information": { "unit": "8.000000", "type": "UN" }, "code_information": [ { "code": "P0378117101", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.09, "maximum": 6.96, "gross_charge": 7.4, "discounted_cash": 4.07, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.29, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.04, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.92, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.27, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.15, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.55, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.43, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.43, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.96, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.51, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.09, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.29, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.55, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.61, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.03, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.96, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.79, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.04, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.88, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.55, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.51, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.29, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.04, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "NAFARELIN ACETATE 2 MG/ML NA SOLN", "drug_information": { "unit": "8.000000", "type": "UN" }, "code_information": [ { "code": "00025016608", "type": "NDC" } ], "standard_charges": [ { "minimum": 3087.56, "maximum": 10299.17, "gross_charge": 10956.56, "discounted_cash": 6026.11, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 6354.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5982.28, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8765.25, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9280.21, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3188.36, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5259.15, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6562.98, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 6552.02, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10299.17, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9641.77, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3087.56, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9313.08, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8217.42, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3860.0, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7450.46, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 10299.17, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8578.99, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5982.28, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 8710.47, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8217.42, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9641.77, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6354.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5982.28, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "NALBUPHINE HCL 10 MG/ML IJ SOLN", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00409146301", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "NALBUPHINE HCL 20 MG/ML IJ SOLN", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00409146501", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "NALOXEGOL OXALATE 25 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "82625880201", "type": "NDC" } ], "standard_charges": [ { "minimum": 8.84, "maximum": 29.49, "gross_charge": 31.37, "discounted_cash": 17.25, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.19, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.13, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.1, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.57, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.13, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.06, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.79, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.76, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.49, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.61, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.84, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.66, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.53, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.05, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.33, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.49, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.56, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.13, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.94, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.53, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.61, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.19, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.13, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "NALOXONE 0.4 MG/ML SOLN 1 ML VIAL (BULK CHARGE)", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "67457029202", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "NALOXONE HCL 0.4 MG/ML IJ SOLN", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "55150032710", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "NALOXONE HCL 2 MG/2ML IJ SOSY", "drug_information": { "unit": "2.000000", "type": "UN" }, "code_information": [ { "code": "76329336901", "type": "NDC" } ], "standard_charges": [ { "minimum": 13.37, "maximum": 44.59, "gross_charge": 47.44, "discounted_cash": 26.09, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.52, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.9, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.95, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.18, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.81, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.77, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.42, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.37, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 44.59, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.75, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.37, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.32, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.58, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.71, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.26, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 44.59, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.15, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.9, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.71, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.58, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.75, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.52, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.9, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "NALOXONE HCL 4 MG/0.1ML NA LIQD", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "45802057884", "type": "NDC" } ], "standard_charges": [ { "minimum": 20.16, "maximum": 67.25, "gross_charge": 71.54, "discounted_cash": 39.35, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.49, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 57.23, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.59, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.82, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.34, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.85, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 67.25, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 62.96, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.16, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.81, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 53.66, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.2, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 48.65, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 67.25, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 56.02, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 56.87, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 53.66, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 62.96, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.49, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "NALOXONE HCL 4 MG/10ML IJ SOLN", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "67457029910", "type": "NDC" } ], "standard_charges": [ { "minimum": 25.2, "maximum": 84.07, "gross_charge": 89.44, "discounted_cash": 49.19, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 51.88, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 48.83, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 71.55, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.76, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.03, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.93, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 53.57, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 53.49, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 84.07, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 78.71, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.2, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 76.02, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 67.08, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.51, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.82, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 84.07, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 70.03, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 48.83, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 71.1, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 67.08, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 78.71, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 51.88, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 48.83, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "NALTREXONE 380 MG IM SUSR", "drug_information": { "unit": "4.200000", "type": "UN" }, "code_information": [ { "code": "65757030001", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.25, "maximum": 4489.1, "gross_charge": 4775.64, "discounted_cash": 2626.6, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2769.87, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.25, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3820.51, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4044.97, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1389.71, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2292.31, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2860.61, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2855.83, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4489.1, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4202.56, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1345.78, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4059.29, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3581.73, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1682.46, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3247.44, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4489.1, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3739.33, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.04, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3796.63, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3581.73, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4202.56, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2769.87, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.25, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "NALTREXONE HCL 50 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68084029121", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.19, "maximum": 3.98, "gross_charge": 4.23, "discounted_cash": 2.33, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.45, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.31, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.38, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.58, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.23, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.03, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.53, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.53, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.98, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.72, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.19, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.6, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.17, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.49, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.88, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.98, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.31, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.31, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.36, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.17, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.72, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.45, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.31, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "NAPHAZOLINE-PHENIRAMINE 0.025-0.3 % OP SOLN", "drug_information": { "unit": "15.000000", "type": "UN" }, "code_information": [ { "code": "00065008515", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "NAPROXEN 125 MG/5ML PO SUSP", "drug_information": { "unit": "500.000000", "type": "UN" }, "code_information": [ { "code": "70954015110", "type": "NDC" } ], "standard_charges": [ { "minimum": 115.79, "maximum": 386.23, "gross_charge": 410.88, "discounted_cash": 225.98, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 238.31, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 224.34, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 328.7, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 348.02, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 119.57, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 197.22, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 246.12, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 245.71, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 386.23, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 361.57, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 115.79, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 349.25, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 308.16, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 144.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 279.4, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 386.23, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 321.72, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 224.34, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 326.65, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 308.16, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 361.57, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 238.31, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 224.34, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "NAPROXEN 250 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "50268059415", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "NAPROXEN 375 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "50268059515", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "NAPROXEN 500 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687049101", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Nasal endoscopy dx", "code_information": [ { "code": "31231", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 143.1, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 106.0, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 14392.16, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 26114.81, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 143.1, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 26114.81, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Nasal/sinus endoscopy surg", "code_information": [ { "code": "31287", "type": "HCPCS" }, { "code": "31288", "type": "HCPCS" }, { "code": "31290", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 5102.55, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3779.67, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 18472.23, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 33518.17, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5102.55, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 33518.17, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "NATALIZUMAB 300 MG/15ML IV CONC", "drug_information": { "unit": "15.000000", "type": "UN" }, "code_information": [ { "code": "64406000801", "type": "NDC" } ], "standard_charges": [ { "minimum": 13.19, "maximum": 24076.37, "gross_charge": 25613.16, "discounted_cash": 14087.24, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 14855.63, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.19, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20490.53, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21694.35, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7453.43, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12294.32, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 15342.28, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 11394.0, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 24076.37, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 22539.58, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 7217.79, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21771.19, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19209.87, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 9023.52, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 17416.95, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 24076.37, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 20055.1, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.8, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 15189.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19209.87, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 22539.58, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 14855.63, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.19, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "NATEGLINIDE 60 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687067321", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "NEBIVOLOL HCL 10 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "62559027730", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.8, "maximum": 6.0, "gross_charge": 6.38, "discounted_cash": 3.51, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.7, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.48, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.1, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.86, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.06, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.82, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.82, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.61, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.8, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.42, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.79, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.25, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.34, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.0, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.48, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.07, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.79, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.61, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.7, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.48, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "NEBIVOLOL HCL 5 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687064121", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.19, "maximum": 3.98, "gross_charge": 4.23, "discounted_cash": 2.33, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.45, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.31, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.38, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.58, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.23, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.03, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.53, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.53, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.98, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.72, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.19, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.6, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.17, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.49, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.88, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.98, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.31, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.31, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.36, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.17, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.72, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.45, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.31, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Neck spine disk surgery", "code_information": [ { "code": "63020", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 5265.64, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3900.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 23928.82, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 43435.41, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5265.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 43435.41, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "NEDOCROMIL SODIUM 2 % OP SOLN", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "00023884205", "type": "NDC" } ], "standard_charges": [ { "minimum": 200.2, "maximum": 667.8, "gross_charge": 710.43, "discounted_cash": 390.74, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 412.05, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 387.89, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 568.34, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 601.73, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 206.74, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 341.01, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 425.55, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 424.84, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 667.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 625.18, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 200.2, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 603.87, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 532.82, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 250.28, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 483.09, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 667.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 556.27, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 387.89, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 564.79, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 532.82, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 625.18, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 412.05, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 387.89, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Needle biopsy chest lining", "code_information": [ { "code": "32400", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1194.28, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 884.65, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 5297.28, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 9612.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1194.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 9612.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Needle biopsy lymph nodes", "code_information": [ { "code": "38505", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1194.28, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 884.65, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 5381.6, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 9765.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1194.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 9765.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Needle biopsy of liver", "code_information": [ { "code": "47000", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1194.28, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 884.65, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 4979.84, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 9036.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1194.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 9036.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Needle biopsy pancreas", "code_information": [ { "code": "48102", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1194.28, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 884.65, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 3837.06, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 6962.4, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1194.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 6962.4, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "NEFAZODONE HCL 50 MG PO TABS", "drug_information": { "unit": "2.000000", "type": "UN" }, "code_information": [ { "code": "00093717801", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.43, "maximum": 4.77, "gross_charge": 5.07, "discounted_cash": 2.79, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.94, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.77, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.06, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.29, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.48, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.43, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.04, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.03, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.77, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.46, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.43, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.31, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.8, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.79, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.45, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.77, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.97, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.77, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.03, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.8, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.46, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.94, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.77, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "NELARABINE 5 MG/ML IV SOLN", "drug_information": { "unit": "50.000000", "type": "UN" }, "code_information": [ { "code": "70710172608_3", "type": "NDC" } ], "standard_charges": [ { "minimum": 39.6, "maximum": 791.08, "gross_charge": 841.57, "discounted_cash": 462.86, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 488.11, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 673.26, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 712.81, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 244.9, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 403.95, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 504.1, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 503.26, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 791.08, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 740.58, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 237.15, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 715.33, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 631.18, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 296.49, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 572.27, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 791.08, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 658.95, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 53.46, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 669.05, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 631.18, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 740.58, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 488.11, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "NELARABINE CHEMO INFUSION", "drug_information": { "unit": "50.000000", "type": "UN" }, "code_information": [ { "code": "70710172608_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 39.6, "maximum": 630.85, "gross_charge": 671.12, "discounted_cash": 369.12, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 389.25, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 536.9, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 568.44, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 195.3, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 322.14, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 402.0, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 401.33, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 630.85, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 590.59, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 189.12, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 570.45, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 503.34, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 236.44, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 456.36, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 630.85, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 525.49, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 53.46, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 533.54, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 503.34, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 590.59, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 389.25, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "NELARABINE CHEMO INFUSION|DISCARDED DRUG NOT ADMINISTERED", "drug_information": { "unit": "50.000000", "type": "UN" }, "code_information": [ { "code": "70710172608", "type": "NDC" } ], "standard_charges": [ { "minimum": 39.6, "maximum": 565.05, "gross_charge": 601.12, "discounted_cash": 330.62, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 348.65, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 480.9, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 509.15, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 174.93, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 288.54, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 360.07, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 359.47, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 565.05, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 528.99, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 169.4, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 510.95, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 450.84, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 211.77, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 408.76, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 565.05, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 470.68, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 53.46, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 477.89, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 450.84, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 528.99, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 348.65, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "NELFINAVIR MESYLATE 250 MG PO TABS", "drug_information": { "unit": "3.000000", "type": "UN" }, "code_information": [ { "code": "63010001030", "type": "NDC" } ], "standard_charges": [ { "minimum": 7.75, "maximum": 25.84, "gross_charge": 27.49, "discounted_cash": 15.12, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.94, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.01, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.99, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.28, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.0, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.47, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.44, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.84, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.19, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.75, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.37, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.62, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.68, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.69, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.84, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.52, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.01, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.85, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.62, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.19, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.94, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.01, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "NELFINAVIR MESYLATE 625 MG PO TABS", "drug_information": { "unit": "2.000000", "type": "UN" }, "code_information": [ { "code": "63010002770", "type": "NDC" } ], "standard_charges": [ { "minimum": 12.91, "maximum": 43.07, "gross_charge": 45.82, "discounted_cash": 25.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.58, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.02, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.66, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.81, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.33, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.99, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.45, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.07, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.32, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.91, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.95, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.37, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.14, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.16, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.07, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.88, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.02, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.43, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.37, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.32, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.58, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.02, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "NEOMYCIN SULFATE 100 MG/ML ORAL SOLUTION", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "P0093117701", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 1158.0, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.47, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "NEOMYCIN SULFATE 500 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "3982203105", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "NEOMYCIN-BACITRACIN ZN-POLYMYX 5-400-10000 OP OINT", "drug_information": { "unit": "3.500000", "type": "GR" }, "code_information": [ { "code": "24208078055", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, 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}, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, 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"plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "NEOMYCIN-POLYMYXIN-GRAMICIDIN 1.75-10000-.025 OP SOLN", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "24208079062", "type": "NDC" } ], "standard_charges": [ { "minimum": 28.0, "maximum": 93.39, "gross_charge": 99.35, "discounted_cash": 54.64, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 57.62, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.25, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 79.48, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 84.15, "standard_charge_percentage": 85.0, 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"standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.43, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 84.45, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.51, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", 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"standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "NEOMYCIN-POLYMYXIN-HC 1 % OT SOLN", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "24208063110", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.49, "maximum": 105.05, "gross_charge": 111.75, "discounted_cash": 61.46, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 64.82, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.02, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", 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"methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 358.88, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 236.54, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 222.67, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "NEOMYCIN-POLYMYXIN-HC 3.5-10000-1 OT SOLN", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "61314064610", "type": "NDC" } ], "standard_charges": [ { "minimum": 53.41, "maximum": 178.16, "gross_charge": 189.53, 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"additional_payer_notes": "N/A", "standard_charge_dollar": 55.15, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 90.97, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 113.53, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 113.34, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 178.16, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": 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"additional_payer_notes": "N/A", "standard_charge_dollar": 150.68, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 142.15, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 166.79, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 109.93, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.48, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "NEOMYCIN-POLYMYXIN-HC 3.5-10000-1 OT SUSP", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "24208063562", "type": "NDC" } ], "standard_charges": [ { "minimum": 55.21, "maximum": 184.17, "gross_charge": 195.93, "discounted_cash": 107.76, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 113.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 106.98, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 156.74, "standard_charge_percentage": 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"standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 184.17, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 172.42, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.21, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 166.54, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 146.95, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 69.03, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 133.23, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 184.17, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 153.41, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 106.98, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 155.76, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 146.95, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 172.42, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 113.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 106.98, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "NEOSALUS EX CREA", "drug_information": { "unit": "100.000000", "type": "GR" }, "code_information": [ { "code": "23710000110", "type": "NDC" } ], "standard_charges": [ { "minimum": 41.01, "maximum": 136.8, "gross_charge": 145.53, "discounted_cash": 80.04, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 84.41, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 79.46, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 116.42, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 123.26, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.35, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 69.85, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.17, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.03, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 136.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 128.07, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.01, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 123.7, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 109.15, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 51.27, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 98.96, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 136.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 113.95, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 79.46, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 115.7, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 109.15, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 128.07, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 84.41, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 79.46, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "NEOSTIGMINE METHYLSULFATE 10 MG/10ML IV SOLN", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "00641614910", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "NEPHRO-VITE 0.8 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "0536141501", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Nerve graft head/neck <4 cm", "code_information": [ { "code": "64885", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4720.44, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3496.62, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 73392.07, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 133171.11, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4720.44, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 133171.11, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Nerve graft head/neck >4 cm", "code_information": [ { "code": "64886", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4720.44, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3496.62, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 41606.3, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 75495.33, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4720.44, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 75495.33, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Nerve palsy fascial graft", "code_information": [ { "code": "15840", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2698.5, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1998.89, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 19451.72, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 35295.47, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2698.5, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 35295.47, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Nerve pedicle transfer", "code_information": [ { "code": "64905", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4720.44, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3496.62, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 31424.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 57019.38, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4720.44, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 57019.38, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Nerve repair w/allograft", "code_information": [ { "code": "64910", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4720.44, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3496.62, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 58606.38, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 106393.84, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4720.44, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": 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"methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 994.98, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1053.43, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 361.92, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 596.99, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 744.99, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 743.74, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1169.1, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1094.47, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 350.48, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1057.16, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 932.79, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 438.16, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 845.73, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1169.1, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 973.83, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 679.07, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 988.76, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 932.79, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1094.47, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 721.36, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 679.07, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Neurovascular pedicle flap", "code_information": [ { "code": "15750", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2698.5, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1998.89, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 17209.22, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 31226.43, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2698.5, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 31226.43, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "NEVIRAPINE 200 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "31722050560", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "NEVIRAPINE 50 MG/5ML PO SUSP", "drug_information": { "unit": "240.000000", "type": "UN" }, "code_information": [ { "code": "65862005724", "type": "NDC" } ], "standard_charges": [ { "minimum": 80.96, "maximum": 270.04, "gross_charge": 287.28, "discounted_cash": 158.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 166.62, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 156.85, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 229.82, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 243.33, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 83.6, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 137.89, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 172.08, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 171.79, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 270.04, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 252.81, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 80.96, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 244.19, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 215.46, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 101.21, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 195.35, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 270.04, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 224.94, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 156.85, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 228.39, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 215.46, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 252.81, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 166.62, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 156.85, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "NIACIN 100 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "80681005700", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "NIACIN 500 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "R0904027260", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "NIACIN ER 250 MG PO TBCR", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "71269025010", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "NIACIN ER 500 MG PO TBCR", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "80681009000", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "NIACINAMIDE 500 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "80681001900", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "NICARDIPINE 40 MG/200 ML RTU", "drug_information": { "unit": "200.000000", "type": "UN" }, "code_information": [ { "code": "43066001610", "type": "NDC" } ], "standard_charges": [ { "minimum": 48.16, "maximum": 160.66, "gross_charge": 170.91, "discounted_cash": 94.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 99.13, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.32, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 136.73, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 144.76, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.73, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.04, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 102.38, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 102.2, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 160.66, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 150.4, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 48.16, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 145.27, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 128.18, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.21, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 116.22, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 160.66, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 133.82, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.32, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 135.87, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 128.18, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 150.4, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 99.13, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.32, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "NICARDIPINE HCL 20 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "42806050109", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.13, "maximum": 7.1, "gross_charge": 7.55, "discounted_cash": 4.15, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.38, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.12, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.04, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.2, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.62, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.52, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.51, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.1, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.64, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.42, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.66, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.66, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.13, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.1, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.91, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.12, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.66, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.64, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.38, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.12, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "NICARDIPINE HCL 30 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68462012190", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.69, "maximum": 8.98, "gross_charge": 9.55, "discounted_cash": 5.25, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.54, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.21, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.64, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.09, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.78, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.58, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.72, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.71, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.98, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.4, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.69, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.12, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.16, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.36, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.49, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.98, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.48, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.21, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.59, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.16, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.4, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.54, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.21, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "NICOTINE 14 MG/24HR TD PT24", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "46122035274", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "NICOTINE 21 MG/24HR TD PT24", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "46122035374", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "NICOTINE POLACRILEX 2 MG MT LOZG", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "R4580234405", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "NIFEDIPINE 10 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00904722961", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "NIFEDIPINE 4 MG/ML ORAL SUSPENSION (IMMEDIATE RELEASE)(PTL)", "drug_information": { "unit": "2.500000", "type": "UN" }, "code_information": [ { "code": "00000000025", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "NIFEDIPINE ER OSMOTIC RELEASE 30 MG PO TB24", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68084059701", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "NIFEDIPINE ER OSMOTIC RELEASE 60 MG PO TB24", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68084059801", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "NIFEDIPINE ER OSMOTIC RELEASE 90 MG PO TB24", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68084060365", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "NILOTINIB HCL 150 MG PO CAPS", "drug_information": { "unit": "2.000000", "type": "UN" }, "code_information": [ { "code": "00078059287", "type": "NDC" } ], "standard_charges": [ { "minimum": 352.98, "maximum": 1177.43, "gross_charge": 1252.59, "discounted_cash": 688.92, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 726.5, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 683.91, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1002.07, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1060.94, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 364.5, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 601.24, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 750.3, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 749.05, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1177.43, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1102.28, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 352.98, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1064.7, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 939.44, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 441.29, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 851.76, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1177.43, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 980.78, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 683.91, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 995.81, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 939.44, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1102.28, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 726.5, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 683.91, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "NILOTINIB HCL 200 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00078052687", "type": "NDC" } ], "standard_charges": [ { "minimum": 176.49, "maximum": 588.72, "gross_charge": 626.3, "discounted_cash": 344.47, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 363.25, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 341.96, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 501.04, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 530.48, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 182.25, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 300.62, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 375.15, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 374.53, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 588.72, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 551.14, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 176.49, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 532.36, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 469.73, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 220.65, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 425.88, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 588.72, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 490.39, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 341.96, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 497.91, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 469.73, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 551.14, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 363.25, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 341.96, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "NIMODIPINE 30 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "69452020920", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "NIMODIPINE 6 MG/ML PO SOLN", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "24338023030", "type": "NDC" } ], "standard_charges": [ { "minimum": 33.11, "maximum": 110.43, "gross_charge": 117.48, "discounted_cash": 64.61, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 68.14, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 64.14, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.98, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 99.51, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.19, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 56.39, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 70.37, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 70.25, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 110.43, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.38, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.11, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 99.86, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.11, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.39, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 79.89, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 110.43, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 91.99, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 64.14, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.4, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.11, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.38, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 68.14, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 64.14, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Nipple exploration", "code_information": [ { "code": "19110", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2822.56, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2090.79, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 7236.64, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 13131.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2822.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 13131.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "NIRSEVIMAB-ALIP 100 MG/ML IM SOSY", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "49281057415", "type": "NDC" } ], "standard_charges": [ { "minimum": 520.01, "maximum": 1734.58, "gross_charge": 1845.3, "discounted_cash": 1014.92, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1070.27, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1007.53, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1476.24, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1562.97, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 536.98, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 885.74, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1105.33, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 1103.49, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1734.58, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1623.86, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 520.01, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1568.51, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1383.98, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 650.1, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1254.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1734.58, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1444.87, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1007.53, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1467.01, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1383.98, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1623.86, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1070.27, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1007.53, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "NIRSEVIMAB-ALIP 50 MG/0.5ML IM SOSY", "drug_information": { "unit": "0.500000", "type": "UN" }, "code_information": [ { "code": "49281057515", "type": "NDC" } ], "standard_charges": [ { "minimum": 520.01, "maximum": 1734.58, "gross_charge": 1845.3, "discounted_cash": 1014.92, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1070.27, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1007.53, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1476.24, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1562.97, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 536.98, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 885.74, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1105.33, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 1103.49, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1734.58, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1623.86, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 520.01, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1568.51, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1383.98, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 650.1, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1254.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1734.58, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1444.87, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1007.53, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1467.01, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1383.98, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1623.86, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1070.27, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1007.53, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "NISOLDIPINE ER 20 MG PO TB24", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00378222201", "type": "NDC" } ], "standard_charges": [ { "minimum": 7.15, "maximum": 23.85, "gross_charge": 25.37, "discounted_cash": 13.95, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.71, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.85, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.3, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.49, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.38, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.18, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.2, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.17, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.85, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.33, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.15, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.56, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.03, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.94, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.25, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.85, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.86, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.85, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.17, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.03, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.33, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.71, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.85, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "NISOLDIPINE ER 8.5 MG PO TB24", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00378209601", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.4, "maximum": 8.01, "gross_charge": 8.52, "discounted_cash": 4.69, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.94, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.65, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.82, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.22, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.48, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.09, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.1, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.09, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.01, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.5, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.24, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.39, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.79, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.01, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.67, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.65, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.77, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.39, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.5, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.94, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.65, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "NITAZOXANIDE 500 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "64980052660", "type": "NDC" } ], "standard_charges": [ { "minimum": 99.89, "maximum": 333.19, "gross_charge": 354.46, "discounted_cash": 194.95, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 205.59, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 193.54, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 283.57, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 300.23, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.15, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 170.14, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 212.32, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 211.97, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 333.19, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 311.92, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 99.89, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 301.29, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 265.85, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 124.88, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 241.03, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 333.19, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 277.54, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 193.54, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 281.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 265.85, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 311.92, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 205.59, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 193.54, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "NITROFURANTOIN 25 MG/5ML PO SUSP", "drug_information": { "unit": "240.000000", "type": "UN" }, "code_information": [ { "code": "70408023932", "type": "NDC" } ], "standard_charges": [ { "minimum": 634.71, "maximum": 2117.19, "gross_charge": 2252.33, "discounted_cash": 1238.78, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1306.35, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1229.77, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1801.86, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1907.72, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 655.43, "standard_charge_percentage": 29.0, "methodology": "percent of total 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88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 634.71, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1914.48, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1689.25, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 793.5, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All 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billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1689.25, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1982.05, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1306.35, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1229.77, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "NITROFURANTOIN MONOHYD MACRO 100 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687063301", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.41, "maximum": 4.71, "gross_charge": 5.01, "discounted_cash": 2.76, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.91, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.74, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.01, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.24, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.46, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.71, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.41, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.26, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.77, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.41, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.71, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.92, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.74, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.98, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.41, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.91, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.74, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "NITROGLYCERIN 0.1 MG/HR TD PT24", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00378910293", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "NITROGLYCERIN 0.2 MG/HR TD PT24", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00378910493", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "NITROGLYCERIN 0.3 MG SL SUBL", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00071041724", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "NITROGLYCERIN 0.3 MG/HR TD PT24", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "50742051530", "type": "NDC" } ], "standard_charges": [ { "minimum": 33.81, "maximum": 112.79, "gross_charge": 119.99, "discounted_cash": 65.99, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 69.59, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.51, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 95.99, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 101.63, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.92, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 57.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 71.87, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 71.75, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - 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"methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.27, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 81.59, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 112.79, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.95, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.51, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 95.39, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 89.99, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 105.59, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 69.59, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.51, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "NITROGLYCERIN 0.4 % RE OINT", "drug_information": { "unit": "30.000000", "type": "GR" }, "code_information": [ { "code": "58914030180", "type": "NDC" } ], "standard_charges": [ { "minimum": 408.84, "maximum": 1363.75, "gross_charge": 1450.8, "discounted_cash": 797.94, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 841.46, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 792.14, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1160.64, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1228.83, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 422.18, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 696.38, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 869.03, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 867.58, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1363.75, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1276.7, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 408.84, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1233.18, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1088.1, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 511.12, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 986.54, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1363.75, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1135.98, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 792.14, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1153.39, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1088.1, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1276.7, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 841.46, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 792.14, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "NITROGLYCERIN 0.4 MG SL SUBL", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68462063945", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.41, "maximum": 4.7, "gross_charge": 5.0, "discounted_cash": 2.75, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.9, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.73, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.24, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.46, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.99, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.7, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.4, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.25, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.76, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.7, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.92, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.73, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.98, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.4, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.9, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.73, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "NITROGLYCERIN 0.4 MG/HR TD PT24", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00378911293", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", 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"additional_generic_notes": "" } ] }, { "description": "NITROGLYCERIN 0.4 MG/SPRAY TL SOLN", "drug_information": { "unit": "5.000000", "type": "GR" }, "code_information": [ { "code": "45802021001", "type": "NDC" } ], "standard_charges": [ { "minimum": 152.71, "maximum": 509.39, "gross_charge": 541.9, "discounted_cash": 298.05, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 314.3, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 295.88, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 433.52, "standard_charge_percentage": 80.0, 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"standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 295.88, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "NITROGLYCERIN 0.6 MG SL SUBL", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00071041924", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All 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}, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "NITROGLYCERIN 0.6 MG/HR TD PT24", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00378911693", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", 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}, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", 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"NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "NITROGLYCERIN 100 MG/250 ML RTU", "drug_information": { "unit": "250.000000", "type": "UN" }, "code_information": [ { "code": "00338105102_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "NITROGLYCERIN 100 MG/250 ML RTU|DISCARDED DRUG NOT ADMINISTERED", "drug_information": { "unit": "250.000000", "type": "UN" }, "code_information": [ { "code": "00338105102", "type": "NDC" } ], "standard_charges": [ { "minimum": 3.18, "maximum": 10.6, "gross_charge": 11.28, "discounted_cash": 6.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.54, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.16, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.02, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.55, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.28, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.41, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.76, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.75, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.93, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.59, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.46, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.97, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.67, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.83, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.16, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.97, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.46, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.93, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.54, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.16, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "NITROGLYCERIN 2 % TD OINT", "drug_information": { "unit": "1.000000", "type": "GR" }, "code_information": [ { "code": "00281032608", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.41, "maximum": 4.69, "gross_charge": 4.99, "discounted_cash": 2.74, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.89, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.99, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.23, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.45, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.99, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.98, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.69, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.39, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.24, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.74, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.76, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.69, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.91, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.97, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.74, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.39, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.89, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "NITROGLYCERIN 5 MG/ML IV SOLN", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "00517481025_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "NITROGLYCERIN 5 MG/ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "00517481025", "type": "NDC" } ], "standard_charges": [ { "minimum": 7.75, "maximum": 25.84, "gross_charge": 27.49, "discounted_cash": 15.12, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.94, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.01, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.99, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.28, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.0, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.47, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.44, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.84, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.19, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.75, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.37, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.62, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.68, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.69, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.84, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.52, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.01, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.85, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.62, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.19, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.94, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.01, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "NITROGLYCERIN 50 MG/250 ML RTU", "drug_information": { "unit": "250.000000", "type": "UN" }, "code_information": [ { "code": "00338104902_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "NITROGLYCERIN 50 MG/250 ML RTU|DISCARDED DRUG NOT ADMINISTERED", "drug_information": { "unit": "250.000000", "type": "UN" }, "code_information": [ { "code": "00338104902", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.98, "maximum": 3.25, "gross_charge": 3.46, "discounted_cash": 1.9, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.01, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.89, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.77, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.93, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.66, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.07, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.07, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.25, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.98, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.94, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.6, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.22, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.35, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.25, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.71, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.89, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.75, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.6, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.01, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.89, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "NITROGLYCERIN IN D5W 100-5 MCG/ML-% IV SOLN", "drug_information": { "unit": "250.000000", "type": "UN" }, "code_information": [ { "code": "00338104702", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "NITROPRUSSIDE SODIUM 25 MG/ML IV SOLN", "drug_information": { "unit": "2.000000", "type": "UN" }, "code_information": [ { "code": "70069026101", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 1158.0, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.72, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "NIVOLUMAB 100 MG/10ML IV SOLN", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "00003377412", "type": "NDC" } ], "standard_charges": [ { "minimum": 2689.29, "maximum": 8970.67, "gross_charge": 9543.27, "discounted_cash": 5248.8, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5535.1, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5210.63, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7634.62, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8083.15, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2777.09, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4580.77, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5716.42, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 5706.88, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8970.67, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8398.08, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2689.29, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8111.78, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7157.45, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3362.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6489.42, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 8970.67, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7472.38, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5210.63, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7586.9, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7157.45, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8398.08, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5535.1, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5210.63, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "NIVOLUMAB 40 MG/4ML IV SOLN", "drug_information": { "unit": "4.000000", "type": "UN" }, "code_information": [ { "code": "00003377211", "type": "NDC" } ], "standard_charges": [ { "minimum": 17.34, "maximum": 3588.28, "gross_charge": 3817.32, "discounted_cash": 2099.53, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2214.05, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.34, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3053.86, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3233.27, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1110.84, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1832.31, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2286.57, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2282.76, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3588.28, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3359.24, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1075.72, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3244.72, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2862.99, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1344.84, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2595.78, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3588.28, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2988.96, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.4, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3034.77, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2862.99, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3359.24, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2214.05, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.34, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "NIVOLUMAB-RELATLIMAB-RMBW 240-80 MG/20ML IV SOLN", "drug_information": { "unit": "40.000000", "type": "UN" }, "code_information": [ { "code": "00003712511_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 11394.0, "maximum": 111535.66, "gross_charge": 118654.96, "discounted_cash": 65260.23, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 68819.88, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 64785.61, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 94923.97, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 100500.75, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34528.59, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 56954.38, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 71074.32, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 11394.0, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 111535.66, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 104416.36, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 33436.97, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 100856.72, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88991.22, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 41802.14, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 80685.37, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 111535.66, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 92906.83, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 64785.61, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 15189.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88991.22, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 104416.36, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 68819.88, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 64785.61, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "NIVOLUMAB-RELATLIMAB-RMBW 240-80 MG/20ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED", "drug_information": { "unit": "40.000000", "type": "UN" }, "code_information": [ { "code": "00003712511", "type": "NDC" } ], "standard_charges": [ { "minimum": 11394.0, "maximum": 111469.86, "gross_charge": 118584.96, "discounted_cash": 65221.73, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 68779.28, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 64747.39, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 94867.97, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 100441.46, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34508.22, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 56920.78, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 71032.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 11394.0, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 111469.86, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 104354.76, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 33417.24, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 100797.22, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88938.72, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 41777.48, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 80637.77, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 111469.86, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 92852.02, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 64747.39, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 15189.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88938.72, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 104354.76, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 68779.28, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 64747.39, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Njx aa&/strd ax nerve img", "code_information": [ { "code": "64417", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 656.23, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 486.1, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 1731.04, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 3141.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 656.23, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 3141.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Njx aa&/strd brch pl nfs img", "code_information": [ { "code": "64416", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 656.23, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 486.1, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 31760.02, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 57629.09, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 656.23, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 57629.09, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Njx aa&/strd brch plxs img", "code_information": [ { "code": "64415", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 656.23, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 486.1, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 2306.4, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 4185.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 656.23, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 4185.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Njx aa&/strd fem nrv nfs img", "code_information": [ { "code": "64448", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 656.23, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 486.1, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 38279.7, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 69459.14, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 656.23, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 69459.14, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Njx aa&/strd femoral nrv img", "code_information": [ { "code": "64447", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 510.46, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 378.12, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 9013.11, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 16354.45, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 510.46, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 16354.45, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Njx aa&/strd gnclr nrv brnch", "code_information": [ { "code": "64454", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 510.46, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 378.12, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 2089.87, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 3792.11, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 510.46, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 3792.11, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Njx aa&/strd gr ocpl nrv", "code_information": [ { "code": "64405", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 217.58, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 161.17, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 2048.48, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 3717.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 217.58, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 3717.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Njx aa&/strd ii ih nerves", "code_information": [ { "code": "64425", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 510.46, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 378.12, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 1732.75, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 3144.11, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 510.46, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 3144.11, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Njx aa&/strd lmbr plex nfs", "code_information": [ { "code": "64449", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 656.23, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 486.1, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 25219.16, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 45760.55, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 656.23, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 45760.55, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Njx aa&/strd nrv nrvtg si jt", "code_information": [ { "code": "64451", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 510.46, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 378.12, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 2008.8, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 3645.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 510.46, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 3645.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Njx aa&/strd ntrcost nrv 1", "code_information": [ { "code": "64420", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 510.46, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 378.12, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 4959.88, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 8999.78, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 510.46, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 8999.78, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Njx aa&/strd other pn/branch", "code_information": [ { "code": "64450", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 510.46, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 378.12, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 2088.16, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 3789.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 510.46, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 3789.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Njx aa&/strd paracrv nrv", "code_information": [ { "code": "64435", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 510.46, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 378.12, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 3625.65, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 6578.79, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 510.46, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 6578.79, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Njx aa&/strd pudendal nerve", "code_information": [ { "code": "64430", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 656.23, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 486.1, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 2921.44, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 5301.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 656.23, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 5301.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Njx aa&/strd sc nrv nfs img", "code_information": [ { "code": "64446", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 656.23, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 486.1, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 15818.83, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 28703.49, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 656.23, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 28703.49, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Njx aa&/strd sciatic nrv img", "code_information": [ { "code": "64445", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 510.46, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 378.12, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 13561.43, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 24607.47, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 510.46, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 24607.47, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Njx aa&/strd sprscap nrv", "code_information": [ { "code": "64418", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 510.46, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 378.12, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 1946.03, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 3531.11, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 510.46, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 3531.11, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Njx aa&/strd tfrm epi c/t 1", "code_information": [ { "code": "64479", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 656.23, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 486.1, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 2375.84, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 4311.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 656.23, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 4311.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Njx aa&/strd tfrm epi l/s 1", "code_information": [ { "code": "64483", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 656.23, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 486.1, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 2068.33, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 3753.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 656.23, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 3753.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Njx b1 sub mtrl sbchdrl dfct", "code_information": [ { "code": "0707T", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2391.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1771.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 11408.5, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 20712.28, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2391.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 20712.28, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Njx cntrst kne arthg/ct/mri", "code_information": [ { "code": "27369", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 2633.76, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 4779.01, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 4779.01, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Njx interlaminar crv/thrc", "code_information": [ { "code": "62320", "type": "HCPCS" }, { "code": "62321", "type": "HCPCS" }, { "code": "62325", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 656.23, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 378.12, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 486.1, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 15563.87, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 28240.88, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 510.46, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 656.23, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 28240.88, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Njx interlaminar lmbr/sac", "code_information": [ { "code": "62322", "type": "HCPCS" }, { "code": "62323", "type": "HCPCS" }, { "code": "62326", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 656.23, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 486.1, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 378.12, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 4376.72, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 7941.63, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 656.23, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 510.46, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 7941.63, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Njx platelet plasma", "code_information": [ { "code": "0232T", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 294.13, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 217.88, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 10157.3, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 18430.6, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 294.13, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 18430.6, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Njx px discography lumbar", "code_information": [ { "code": "62290", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 2539.52, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 4608.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 4608.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Njx px nfrosgrm &/urtrgrm", "code_information": [ { "code": "50430", "type": "HCPCS" }, { "code": "50431", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 491.99, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 364.44, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 1165.6, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 2115.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 491.99, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 2115.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Njx sclrsnt 1 incmptnt vein", "code_information": [ { "code": "36470", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 294.49, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 2805.81, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 5091.19, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 294.49, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 5091.19, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Njx sclrsnt mlt incmptnt vn", "code_information": [ { "code": "36471", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 294.49, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 2377.33, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 4313.7, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 294.49, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 4313.7, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Njx sclrsnt spider veins", "code_information": [ { "code": "36468", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 294.49, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 218.14, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 19357.67, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 35124.81, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 294.49, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 35124.81, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "NOGAPENDEKIN ALFA INBAKIC-PMLN 400 MCG/0.4ML IS SOLN", "drug_information": { "unit": "0.400000", "type": "UN" }, "code_information": [ { "code": "81481080301", "type": "NDC" } ], "standard_charges": [ { "minimum": 11394.0, "maximum": 100956.0, "gross_charge": 107400.0, "discounted_cash": 59070.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 62292.0, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 58640.4, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 85920.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 90967.8, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 31253.4, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 51552.0, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 64332.6, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 11394.0, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 100956.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 94512.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 30265.32, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 91290.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 80550.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 37837.02, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 73032.0, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 100956.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 84094.2, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 58640.4, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 15189.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 80550.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 94512.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 62292.0, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 58640.4, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "NOREPINEPHRINE BITARTRATE 1 MG/ML IV SOLN", "drug_information": { "unit": "4.000000", "type": "UN" }, "code_information": [ { "code": "43066099710", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 1158.0, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.72, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "NOREPINEPHRINE-SODIUM CHLORIDE 8-0.9 MG/250ML-% IV SOLN (TITRATABLE/ICU)", "drug_information": { "unit": "250.000000", "type": "UN" }, "code_information": [ { "code": "71266501502", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "NORETHIN ACE-ETH ESTRAD-FE 1-20 MG-MCG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00378728353", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "NORETHIN ACE-ETH ESTRAD-FE 1.5-30 MG-MCG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68180086673", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "NORETHIN-ETH ESTRAD TRIPHASIC 0.5/1/0.5-35 MG-MCG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00555906667", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "NORETHINDRONE 0.35 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00378729253", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "NORETHINDRONE ACET-ETHINYL EST 1-20 MG-MCG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68462013281", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "NORETHINDRONE ACET-ETHINYL EST 1.5-30 MG-MCG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68462050481", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "NORETHINDRONE ACETATE 5 MG PO TABS", "drug_information": { "unit": "0.500000", "type": "UN" }, "code_information": [ { "code": "R6846230450", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "NORETHINDRONE-ETH ESTRADIOL 0.4-35 MG-MCG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68462031629", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "NORETHINDRONE-ETH ESTRADIOL 0.5-35 MG-MCG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00555900867", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "NORETHINDRONE-ETH ESTRADIOL 1-5 MG-MCG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00093312298", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.5, "maximum": 4.99, "gross_charge": 5.31, "discounted_cash": 2.92, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.08, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.9, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.25, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.55, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.55, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.99, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.67, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.5, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.51, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.98, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.87, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.61, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.99, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.16, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.9, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.22, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.98, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.67, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.08, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.9, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "NORGESTREL-ETHINYL ESTRADIOL 0.3-30 MG-MCG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "51862056406", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "NORMOSOL-R PH 7.4 IV BOLUS", "drug_information": { "unit": "1000.000000", "type": "UN" }, "code_information": [ { "code": "00990767009", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 1158.0, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.72, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "NORMOSOL-R PH 7.4 IV SOLN", "drug_information": { "unit": "1000.000000", "type": "UN" }, "code_information": [ { "code": "00990767009_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 19.73, "maximum": 1158.0, "gross_charge": 70.0, "discounted_cash": 38.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.76, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.37, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.93, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.86, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.73, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.66, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.6, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.81, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.65, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "NORTRIPTYLINE HCL 10 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "75907006901", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "NORTRIPTYLINE HCL 10 MG/5ML PO SOLN", "drug_information": { "unit": "473.000000", "type": "UN" }, "code_information": [ { "code": "00121067816", "type": "NDC" } ], "standard_charges": [ { "minimum": 100.23, "maximum": 334.34, "gross_charge": 355.68, "discounted_cash": 195.62, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 206.29, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 194.2, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 284.54, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 301.26, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.5, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 170.73, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 213.05, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 212.7, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 334.34, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 313.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 100.23, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 302.33, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 266.76, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 125.31, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 241.86, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 334.34, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 278.5, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 194.2, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 282.77, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 266.76, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 313.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 206.29, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 194.2, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "NORTRIPTYLINE HCL 50 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "50268060515", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "NORTRIPTYLINE HCL 75 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "5167240041", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Nps surg dilat eust tube bi", "code_information": [ { "code": "69706", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4360.43, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3229.95, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 16280.66, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 29541.52, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4360.43, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 29541.52, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Nps surg dilat eust tube uni", "code_information": [ { "code": "69705", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4360.43, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3229.95, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 15475.16, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 28462.04, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4360.43, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 28462.04, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Nrv grf 1strnd arm/leg >4 cm", "code_information": [ { "code": "64893", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4720.44, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3496.62, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 20638.15, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 37448.24, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4720.44, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 37448.24, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Nrv rpr w/nrv algrft 1st", "code_information": [ { "code": "64912", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4720.44, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3496.62, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 20924.1, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 37967.11, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4720.44, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 37967.11, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Nsl/sins ndsc frnt tiss rmvl", "code_information": [ { "code": "31276", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 5102.55, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3779.67, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 21404.99, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 38839.72, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5102.55, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 38839.72, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Nsl/sins ndsc med/inf dcmprn", "code_information": [ { "code": "31292", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 5102.55, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3779.67, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 14142.61, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 25809.62, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5102.55, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 25809.62, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Nsl/sins ndsc sphn tiss rmvl", "code_information": [ { "code": "31259", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 5102.55, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3779.67, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 21773.26, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 39507.96, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5102.55, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 39507.96, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Nsl/sins ndsc srg nsl hemrrg", "code_information": [ { "code": "31238", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1271.11, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 941.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 11381.14, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 20651.29, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1271.11, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 20651.29, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Nsl/sins ndsc surg bx polypc", "code_information": [ { "code": "31237", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1271.11, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 941.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 11750.24, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 21320.99, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1271.11, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 21320.99, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Nsl/sins ndsc surg frnt sins", "code_information": [ { "code": "31296", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 5102.55, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3779.67, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 13825.7, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 25086.96, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5102.55, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 25086.96, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Nsl/sins ndsc surg frnt&sphn", "code_information": [ { "code": "31298", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 5102.55, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3779.67, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 12700.3, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 23295.54, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5102.55, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 23295.54, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Nsl/sins ndsc surg max sins", "code_information": [ { "code": "31295", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 5102.55, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3779.67, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 11200.18, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 20565.32, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5102.55, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 20565.32, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Nsl/sins ndsc surg on dcmprn", "code_information": [ { "code": "31294", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 5102.55, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3779.67, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 27262.94, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 49469.02, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5102.55, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 49469.02, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Nsl/sins ndsc surg sphn sins", "code_information": [ { "code": "31297", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 5102.55, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3779.67, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 20240.48, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 37092.54, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5102.55, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 37092.54, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Nsl/sins ndsc tot w/sphendt", "code_information": [ { "code": "31257", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 5102.55, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3779.67, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 20186.78, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 36629.25, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5102.55, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 36629.25, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Nsl/sins ndsc total", "code_information": [ { "code": "31253", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 5102.55, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3779.67, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 21250.22, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 38558.87, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5102.55, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 38558.87, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Nsl/sins ndsc w/prtl ethmdct", "code_information": [ { "code": "31254", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 5102.55, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3779.67, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 15716.61, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 28518.06, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5102.55, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 28518.06, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Nsl/sins ndsc w/tot ethmdct", "code_information": [ { "code": "31255", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 5102.55, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3779.67, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 15585.44, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 28280.03, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5102.55, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 28280.03, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Nsl/sinus endoscopy surg dcr", "code_information": [ { "code": "31239", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2717.65, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": 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"standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 16917.55, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Nsl/sns ndsc cnch bull rescj", "code_information": [ { "code": "31240", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1271.11, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 941.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 15676.56, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 28445.37, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1271.11, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 28445.37, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Nsl/sns ndsc lig sphnptn art", "code_information": [ { "code": "31241", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1271.11, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", 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charges" } ], "additional_generic_notes": "" } ] }, { "description": "NUSINERSEN 12 MG/5ML IT SOLN", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "64406005801_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 11394.0, "maximum": 400612.48, "gross_charge": 426183.49, "discounted_cash": 234400.92, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 247186.42, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 232696.19, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 340946.79, 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"payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 319637.62, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 150144.44, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 289804.77, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 400612.48, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", 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"plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 247186.42, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 232696.19, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "NUSINERSEN 12 MG/5ML IT SOLN|DISCARDED DRUG NOT ADMINISTERED", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "64406005801", "type": "NDC" } ], "standard_charges": [ { "minimum": 11394.0, "maximum": 400546.68, "gross_charge": 426113.49, "discounted_cash": 234362.42, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 247145.82, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 232657.97, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 340890.79, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 360918.13, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 123999.03, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": 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Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 120078.78, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 362196.47, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 319585.12, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 150119.78, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 289757.17, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 400546.68, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 333646.86, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 232657.97, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 15189.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 319585.12, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 374979.87, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 247145.82, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 232657.97, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "NUTRISOURCE FIBER PO PACK", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "43900097647", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "NYSTATIN 100000 UNIT/GM EX CREA", "drug_information": { "unit": "15.000000", "type": "GR" }, "code_information": [ { "code": "00713067815", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.6, "maximum": 8.68, "gross_charge": 9.23, "discounted_cash": 5.08, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.35, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.04, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.38, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.82, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.69, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.43, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.53, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.52, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.68, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.12, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.6, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.85, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.92, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.25, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.28, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.68, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.23, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.04, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.34, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.92, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.12, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.35, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.04, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "NYSTATIN 100000 UNIT/GM EX OINT", "drug_information": { "unit": "30.000000", "type": "GR" }, "code_information": [ { "code": "72578008904", "type": "NDC" } ], "standard_charges": [ { "minimum": 4.06, "maximum": 13.54, "gross_charge": 14.4, "discounted_cash": 7.92, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.35, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.86, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.52, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.2, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.19, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.91, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.63, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.61, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.54, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.67, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.06, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.24, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.8, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.07, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.79, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.54, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.28, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.86, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.8, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.67, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.35, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.86, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "NYSTATIN 100000 UNIT/GM EX POWD", "drug_information": { "unit": "15.000000", "type": "GR" }, "code_information": [ { "code": "00574200815", "type": "NDC" } ], "standard_charges": [ { "minimum": 3.09, "maximum": 10.32, "gross_charge": 10.98, "discounted_cash": 6.04, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.37, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.78, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.3, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.27, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.58, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.57, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.32, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.66, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.09, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.33, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.24, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.87, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.47, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.32, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.6, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.73, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.24, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.66, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.37, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "NYSTATIN 100000 UNIT/ML MT SUSP", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "00121086800", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.21, "maximum": 4.02, "gross_charge": 4.28, "discounted_cash": 2.35, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.48, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.34, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.42, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.63, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.25, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.05, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.56, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.56, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.02, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.77, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.21, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.64, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.21, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.51, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.91, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.02, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.35, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.34, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.21, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.77, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.48, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.34, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "NYSTATIN 500000 UNITS PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "2315505101", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "NYSTATIN-TRIAMCINOLONE 100000-0.1 UNIT/GM-% EX CREA", "drug_information": { "unit": "30.000000", "type": "GR" }, "code_information": [ { "code": "45802088094", "type": "NDC" } ], "standard_charges": [ { "minimum": 3.62, "maximum": 12.08, "gross_charge": 12.85, "discounted_cash": 7.07, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.45, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.02, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.28, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.74, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.17, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.7, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.68, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.08, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.31, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.62, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.92, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.64, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.53, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.74, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.08, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.06, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.02, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.22, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.64, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.31, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.45, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.02, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "NYSTATIN-TRIAMCINOLONE 100000-0.1 UNIT/GM-% EX OINT", "drug_information": { "unit": "30.000000", "type": "GR" }, "code_information": [ { "code": "62332058530", "type": "NDC" } ], "standard_charges": [ { "minimum": 8.88, "maximum": 29.61, "gross_charge": 31.5, "discounted_cash": 17.33, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.27, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.2, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.68, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.17, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.12, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.87, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.84, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.61, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.72, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.88, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.78, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.63, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.1, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.42, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.61, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.66, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.2, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.04, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.63, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.72, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.27, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.2, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "OBINUTUZUMAB 1000 MG/40ML IV SOLN", "drug_information": { "unit": "40.000000", "type": "UN" }, "code_information": [ { "code": "50242007001", "type": "NDC" } ], "standard_charges": [ { "minimum": 6270.89, "maximum": 20917.8, "gross_charge": 22252.98, "discounted_cash": 12239.14, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 12906.73, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 12150.13, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17802.38, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 18848.27, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6475.62, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10681.43, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 13329.54, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 11394.0, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20917.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19582.62, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 6270.89, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 18915.03, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16689.74, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 7839.72, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 15132.03, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 20917.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 17424.08, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 12150.13, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 15189.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16689.74, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19582.62, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 12906.73, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 12150.13, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "OCRELIZUMAB 300 MG/10ML IV SOLN", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "50242015001", "type": "NDC" } ], "standard_charges": [ { "minimum": 11394.0, "maximum": 55594.55, "gross_charge": 59143.14, "discounted_cash": 32528.73, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 34303.02, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 32292.15, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 47314.51, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 50094.24, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17210.65, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 28388.71, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 35426.74, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 11394.0, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 55594.55, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52045.96, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 16666.54, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 50271.67, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 44357.36, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 20836.13, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 40217.34, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 55594.55, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 46309.08, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 32292.15, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 15189.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 44357.36, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52045.96, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 34303.02, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 32292.15, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "OCTREOTIDE ACETATE 10 MG IM KIT", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00078081181", "type": "NDC" } ], "standard_charges": [ { "minimum": 117.32, "maximum": 9541.64, "gross_charge": 10150.68, "discounted_cash": 5582.87, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5887.39, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 117.32, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8120.54, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8597.63, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2953.85, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4872.33, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6080.26, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 6070.11, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9541.64, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8932.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2860.46, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8628.08, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7613.01, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3576.08, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6902.46, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 9541.64, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7947.98, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 158.39, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 8069.79, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7613.01, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8932.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5887.39, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 117.32, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "OCTREOTIDE ACETATE 100 MCG/ML IJ SOLN", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00641617510", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "OCTREOTIDE ACETATE 1000 MCG/ML IJ SOLN", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "63323037905", "type": "NDC" } ], "standard_charges": [ { "minimum": 82.03, "maximum": 273.62, "gross_charge": 291.09, "discounted_cash": 160.1, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 168.83, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 158.94, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 232.87, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 246.55, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 84.71, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 139.72, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 174.36, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 174.07, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 273.62, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 256.16, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.03, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 247.43, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 218.32, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 102.55, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 197.94, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 273.62, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 227.92, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 158.94, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 231.42, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 218.32, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 256.16, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 168.83, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 158.94, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "OCTREOTIDE ACETATE 20 MG IM KIT", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00078081881", "type": "NDC" } ], "standard_charges": [ { "minimum": 117.32, "maximum": 12501.17, "gross_charge": 13299.12, "discounted_cash": 7314.52, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 7713.49, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 117.32, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10639.3, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11264.35, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3870.04, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6383.58, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7966.17, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 7952.87, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12501.17, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11703.23, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3747.69, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11304.25, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9974.34, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 4685.28, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 9043.4, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 12501.17, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 10413.21, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 158.39, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 10572.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9974.34, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11703.23, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7713.49, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 117.32, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "OCTREOTIDE ACETATE 30 MG IM KIT", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00078082581", "type": "NDC" } ], "standard_charges": [ { "minimum": 117.32, "maximum": 18719.53, "gross_charge": 19914.39, "discounted_cash": 10952.91, "setting": 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"PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17524.66, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 5611.88, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16927.23, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14935.79, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 7015.84, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 13541.79, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 18719.53, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 15592.97, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 158.39, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 15189.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14935.79, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17524.66, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 11550.35, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 117.32, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "OCTREOTIDE ACETATE 50 MCG/ML IJ SOLN", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00641617410", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": 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charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Ocular photodynamic ther", "code_information": [ { "code": "67221", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 404.37, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 299.54, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 3508.37, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 6366.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 404.37, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 6366.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Ocular reconst transplant", "code_information": [ { "code": "65780", "type": "HCPCS" }, { "code": "65782", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2779.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2058.97, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 13449.98, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 24405.2, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", 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"additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", 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"Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "OFLOXACIN 0.3 % OT SOLN", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "24208041005", "type": "NDC" } ], "standard_charges": [ { "minimum": 82.04, "maximum": 273.66, "gross_charge": 291.13, "discounted_cash": 160.12, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 168.86, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 158.96, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 232.9, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 246.59, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 84.72, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 139.74, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 174.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 174.1, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 273.66, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 256.19, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.04, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 247.46, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 218.35, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 102.57, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 197.97, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 273.66, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 227.95, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 158.96, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 231.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 218.35, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 256.19, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 168.86, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 158.96, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "OLANZAPINE 10 MG IM SOLR", "drug_information": { "unit": "0.500000", "type": "UN" }, "code_information": [ { "code": "55150030801", "type": "NDC" } ], "standard_charges": [ { "minimum": 22.61, "maximum": 75.44, "gross_charge": 80.25, "discounted_cash": 44.14, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.55, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.82, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 64.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 67.97, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.35, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.52, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 48.07, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.99, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.44, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 70.62, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.61, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 68.21, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.19, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.27, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.57, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.44, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 62.84, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.82, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.19, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 70.62, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.55, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.82, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "OLANZAPINE 10 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68084074001", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "OLANZAPINE 10 MG PO TBDP", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "64380017302", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": 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charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", 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{ "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "OLANZAPINE 15 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68084052801", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "OLANZAPINE 15 MG PO TBDP", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "64380017402", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "OLANZAPINE 2.5 MG PO TABS", "drug_information": { "unit": "2.000000", "type": "UN" }, "code_information": [ { "code": "68084052501", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "OLANZAPINE 2.5 MG PO TBDP", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "R3334208307", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "OLANZAPINE 20 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68084052901", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "OLANZAPINE 5 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60505311100", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "OLANZAPINE 5 MG PO TBDP", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "64380017202", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "OLANZAPINE 7.5 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60505311200", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "OLIPUDASE ALFA-RPCP 20 MG IV SOLR", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "58468005001", "type": "NDC" } ], "standard_charges": [ { "minimum": 6158.6, "maximum": 20543.25, "gross_charge": 21854.52, "discounted_cash": 12019.99, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 12675.62, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 11932.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17483.62, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 18510.78, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6359.67, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10490.17, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 13090.86, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 11394.0, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20543.25, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19231.98, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 6158.6, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 18576.34, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16390.89, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 7699.35, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { 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"standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16390.89, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19231.98, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 12675.62, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 11932.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "OLMESARTAN MEDOXOMIL 20 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68462043730", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", 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"UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "OLMESARTAN MEDOXOMIL 40 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68462043830", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "OLMESARTAN MEDOXOMIL 5 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68462043630", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "OLOPATADINE HCL 0.2 % OP SOLN", "drug_information": { "unit": "2.500000", "type": "UN" }, "code_information": [ { "code": "58602000739", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "OMADACYCLINE TOSYLATE 100 MG IV SOLR", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "71715000102", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.07, "maximum": 1557.15, "gross_charge": 1656.54, "discounted_cash": 911.1, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 960.79, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.07, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1325.23, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1403.09, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 482.05, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 795.14, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 992.27, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 990.61, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1557.15, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1457.76, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 466.81, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1408.06, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1242.41, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 583.6, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1126.45, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1557.15, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1297.07, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.8, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1316.95, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1242.41, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1457.76, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 960.79, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.07, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "OMADACYCLINE TOSYLATE 150 MG PO TABS", "drug_information": { "unit": "2.000000", "type": "UN" }, "code_information": [ { "code": "71715000221", "type": "NDC" } ], "standard_charges": [ { "minimum": 477.57, "maximum": 1593.04, "gross_charge": 1694.72, "discounted_cash": 932.1, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 982.94, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 925.32, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1355.78, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1435.43, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 493.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 813.47, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1015.14, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 1013.44, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1593.04, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1491.35, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 477.57, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1440.51, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1271.04, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 597.05, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1152.41, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1593.04, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1326.97, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 925.32, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1347.3, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1271.04, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1491.35, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 982.94, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 925.32, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "OMALIZUMAB 150 MG SC SOLR", "drug_information": { "unit": "1.200000", "type": "UN" }, "code_information": [ { "code": "50242004062", "type": "NDC" } ], "standard_charges": [ { "minimum": 1170.85, "maximum": 3905.59, "gross_charge": 4154.88, "discounted_cash": 2285.18, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2409.83, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2268.56, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3323.9, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3519.18, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1209.07, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1994.34, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2488.77, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2484.62, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3905.59, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3656.29, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1170.85, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3531.65, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3116.16, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1463.76, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2825.32, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3905.59, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3253.27, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2268.56, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3303.13, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3116.16, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3656.29, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2409.83, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2268.56, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "OMEGA-3-ACID ETHYL ESTERS 1 G PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "64380076111", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "OMEPRAZOLE 20 MG PO CPDR", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68084012801", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ONABOTULINUMTOXINA (BOTOX) 100 UNITS WITH 0.9% NS (10ML)", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "08252114501", "type": "NDC" } ], "standard_charges": [ { "minimum": 677.45, "maximum": 2259.76, "gross_charge": 2404.0, "discounted_cash": 1322.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1394.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1312.58, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1923.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2036.19, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 699.56, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1153.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1440.0, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 1437.59, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2259.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2115.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 677.45, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2043.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1803.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 846.93, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1634.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2259.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1882.33, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1312.58, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1911.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1803.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2115.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1394.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1312.58, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ONABOTULINUMTOXINA (COSMETIC) 100 UNITS IM SOLR", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00023923201", "type": "NDC" } ], "standard_charges": [ { "minimum": 3.5, "maximum": 2259.76, "gross_charge": 2404.0, "discounted_cash": 1322.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1394.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.5, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1923.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2036.19, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 699.56, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1153.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1440.0, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 1437.59, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2259.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2115.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 677.45, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2043.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1803.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", 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Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1911.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1803.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2115.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1394.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.5, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "ONABOTULINUMTOXINA (COSMETIC) 50 UNITS IM SOLR", "drug_information": { "unit": "50.000000", "type": "UN" }, "code_information": [ { "code": "00023391950", "type": "NDC" } ], "standard_charges": [ { "minimum": 3.5, "maximum": 1361.12, "gross_charge": 1448.0, "discounted_cash": 796.4, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 839.84, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.5, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.4, "standard_charge_percentage": 80.0, 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"additional_payer_notes": "N/A", "standard_charge_dollar": 2273.92, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1498.72, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.5, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "ONABOTULINUMTOXINA 200 UNITS IJ SOLR", "drug_information": { "unit": "200.000000", "type": "UN" }, "code_information": [ { "code": "00023392102", "type": "NDC" } ], "standard_charges": [ { "minimum": 3.5, "maximum": 3643.44, "gross_charge": 3876.0, "discounted_cash": 2131.8, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare 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"methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1092.26, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3294.6, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2907.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1365.51, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All 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"PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5992500.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5610000.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1796475.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5418750.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4781250.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2245912.5, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4335000.0, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5992500.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4991625.0, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", 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"methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5610000.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1796475.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5418750.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4781250.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2245912.5, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4335000.0, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5992500.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4991625.0, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3480750.0, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 15189.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4781250.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5610000.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3697500.0, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3480750.0, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ONCOLOGY MOUTHWASH (COMPOUNDED)", "drug_information": { "unit": "15.000000", "type": "UN" }, "code_information": [ { "code": "00067628212R", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ONDANSETRON 2 MG/ML SYRINGE (PEDS)", "drug_information": { "unit": "2.000000", "type": "UN" }, "code_information": [ { "code": "60505613005", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ONDANSETRON 4 MG PO TBDP", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "57237007710", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ONDANSETRON 8 MG PO TBDP", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68001024717", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ONDANSETRON HCL 4 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "1671415901", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ONDANSETRON HCL 4 MG/2ML IJ SOLN", "drug_information": { "unit": "2.000000", "type": "UN" }, "code_information": [ { "code": "60505613005_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ONDANSETRON HCL 4 MG/5ML PO SOLN", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "17856055505", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.56, "maximum": 5.22, "gross_charge": 5.55, "discounted_cash": 3.05, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.22, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.03, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.44, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.7, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.62, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.66, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.32, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.32, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.22, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.88, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.56, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.72, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.16, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.96, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.77, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.22, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.35, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.03, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.41, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.16, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.88, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.22, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.03, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ONDANSETRON HCL 8 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68084022101", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Open ablate liver tumor rf", "code_information": [ { "code": "47380", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 39411.51, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 71512.93, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 71512.93, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Open bx/exc inguinofem nodes", "code_information": [ { "code": "38531", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2822.56, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2090.79, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 12548.8, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 22770.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2822.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 22770.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Open nasoethmoid fx w/ fixj", "code_information": [ { "code": "21339", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4360.43, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3229.95, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 75110.7, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 136403.09, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4360.43, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 136403.09, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Open nasoethmoid fx w/o fixj", "code_information": [ { "code": "21338", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4360.43, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3229.95, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 29985.86, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 54409.85, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4360.43, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 54409.85, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Open thrombect av fistula", "code_information": [ { "code": "36831", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 3984.54, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2951.51, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 12976.87, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 23907.65, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3984.54, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 23907.65, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Open tx dprsd front sinus fx", "code_information": [ { "code": "21343", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 24766.79, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 44939.75, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 44939.75, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Open tx nose fx uncomplicatd", "code_information": [ { "code": "21325", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2390.47, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1770.72, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 22926.69, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 41600.83, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2390.47, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 41600.83, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Open tx septal fx w/wo stabj", "code_information": [ { "code": "21336", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2391.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1771.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 12487.22, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 22658.25, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2391.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 22658.25, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Open/perq place stent 1st", "code_information": [ { "code": "37236", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 8359.13, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 6191.95, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 19846.82, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 36026.79, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8359.13, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 36026.79, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Open/perq place stent same", "code_information": [ { "code": "37238", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 8359.13, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 6191.95, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 29019.8, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 52656.92, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8359.13, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 52656.92, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "OPIUM 10 MG/ML (1%) PO TINC", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "R6255901534", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.25, "maximum": 7.52, "gross_charge": 8.0, "discounted_cash": 4.4, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.4, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.78, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.33, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.84, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.79, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.25, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.8, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.82, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.44, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.26, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.36, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Opn impltj crnl nrv nea&pg", "code_information": [ { "code": "64568", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 22462.08, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 16638.58, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 77747.66, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 141074.38, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 22462.08, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 141074.38, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Opn impltj nea perph nerve", "code_information": [ { "code": "64575", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 9191.87, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 6808.79, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 63750.7, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 115676.68, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 9191.87, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 115676.68, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Opn impltj nea sacral nerve", "code_information": [ { "code": "64581", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4837.51, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3583.34, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 19680.56, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 35710.69, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4837.51, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 35710.69, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Opn mpltj hpglsl nstm ary pg", "code_information": [ { "code": "64582", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 22462.08, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 16638.58, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 56439.19, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 102425.44, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 22462.08, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 102425.44, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Opn tx complx malar fx", "code_information": [ { "code": "21365", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4360.43, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3229.95, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 15881.56, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 28857.38, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4360.43, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 28857.38, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Opn tx complx malar w/grft", "code_information": [ { "code": "21366", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4360.43, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3229.95, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 33600.07, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 60967.95, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4360.43, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 60967.95, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Opn tx dprsd malar fracture", "code_information": [ { "code": "21360", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4360.43, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3229.95, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 106976.01, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 194109.75, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4360.43, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 194109.75, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Opn tx orbit fx combined", "code_information": [ { "code": "21387", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4360.43, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3229.95, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 16732.24, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 30360.92, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4360.43, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 30360.92, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Opn tx orbit fx periorbital", "code_information": [ { "code": "21386", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4360.43, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3229.95, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 9598.68, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 17504.51, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4360.43, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 17504.51, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Opn tx orbit fx transantral", "code_information": [ { "code": "21385", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4360.43, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3229.95, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 24824.81, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 45045.01, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4360.43, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 45045.01, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Opn tx orbit fx w/implant", "code_information": [ { "code": "21407", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4360.43, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3229.95, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 16192.66, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 29433.41, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4360.43, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 29433.41, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Opn tx orbit fx w/o implant", "code_information": [ { "code": "21406", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4360.43, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3229.95, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 34528.66, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 62652.91, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4360.43, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 62652.91, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Opn tx orbit periorbt w/grft", "code_information": [ { "code": "21395", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4360.43, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3229.95, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 33600.07, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 60967.95, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4360.43, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 60967.95, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Opn tx orbit periorbtl implt", "code_information": [ { "code": "21390", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4360.43, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3229.95, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 14286.41, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 25922.9, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4360.43, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 25922.9, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Optx acrclv dslc aq/chrn grf", "code_information": [ { "code": "23552", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 5265.64, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3900.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 17518.88, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 31788.29, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5265.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 31788.29, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Optx acromclv dislc aqt/chrn", "code_information": [ { "code": "23550", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 5265.64, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3900.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 15868.83, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 28797.87, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5265.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 28797.87, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Optx clavicular fx w/int fix", "code_information": [ { "code": "23515", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 5265.64, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3900.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 18853.03, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 34209.13, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5265.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 34209.13, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Optx gr hmrl tbrs fx int fix", "code_information": [ { "code": "23630", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 5265.64, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3900.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 25825.84, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 46861.41, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5265.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 46861.41, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Optx medial ankle fx", "code_information": [ { "code": "27766", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 5265.64, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3900.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 11255.31, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 20422.96, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5265.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 20422.96, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Optx of rib fx w/fixj scope", "code_information": [ { "code": "21811", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 5265.64, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3900.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 20029.1, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 36699.01, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5265.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 36699.01, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Optx prox humrl fx w/int fix", "code_information": [ { "code": "23615", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 9484.13, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 7025.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 22123.16, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 40146.45, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 9484.13, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 40146.45, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Optx scapular fx w/int fixj", "code_information": [ { "code": "23585", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 5265.64, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3900.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 17039.32, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 30933.15, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5265.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 30933.15, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Optx sho dislc fx", "code_information": [ { "code": "23670", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 5265.64, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3900.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 30816.16, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 55916.42, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5265.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 55916.42, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Optx sho dislc neck fx fixj", "code_information": [ { "code": "23680", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 9484.13, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 7025.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 19253.9, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 34936.52, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 9484.13, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 34936.52, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Optx strclv dslc aq/chrn grf", "code_information": [ { "code": "23532", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 5265.64, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3900.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 25681.76, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 46599.98, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5265.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 46599.98, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ORA-PLUS PO LIQD", "drug_information": { "unit": "473.000000", "type": "UN" }, "code_information": [ { "code": "00574030316", "type": "NDC" } ], "standard_charges": [ { "minimum": 9.71, "maximum": 32.38, "gross_charge": 34.45, "discounted_cash": 18.95, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.98, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.81, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.56, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.18, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.02, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.54, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.64, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.6, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.38, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.32, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.71, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.28, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.84, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.14, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.43, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.38, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.97, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.81, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.39, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.84, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.32, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.98, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.81, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ORA-SWEET PO SYRP", "drug_information": { "unit": "473.000000", "type": "UN" }, "code_information": [ { "code": "00574030416", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.29, "maximum": 37.68, "gross_charge": 40.08, "discounted_cash": 22.04, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.25, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.88, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.06, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.95, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.66, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.24, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.01, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.97, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.68, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.27, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.29, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.07, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.06, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.12, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.25, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.68, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.38, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.88, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.86, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.06, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.27, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.25, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.88, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Orchiectomy partial", "code_information": [ { "code": "54522", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2542.24, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1883.14, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 9536.91, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 17304.88, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2542.24, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 17304.88, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Orchiopexy ingun/scrot appr", "code_information": [ { "code": "54640", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2601.27, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1926.87, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 13004.25, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 23596.41, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2601.27, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 23596.41, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "OSELTAMIVIR PHOSPHATE 30 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68180067511", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "OSELTAMIVIR PHOSPHATE 6 MG/ML PO SUSR", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "27241013909", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "OSELTAMIVIR PHOSPHATE 75 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68180067711", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Osteochondral knee allograft", "code_information": [ { "code": "27415", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 9484.13, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 7025.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 45429.97, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 82433.42, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 9484.13, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 82433.42, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Other bone graft microvasc", "code_information": [ { "code": "20962", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 50449.11, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 91540.79, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 91540.79, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "OXACILLIN 100 MG/ML SYRINGE", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "25021014610_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "OXACILLIN 100 MG/ML SYRINGE (NICU)", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "25021014610_3", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "OXACILLIN 167 MG/ML IM INJECTION", "drug_information": { "unit": "6.000000", "type": "UN" }, "code_information": [ { "code": "08252014610", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "OXACILLIN 2 GM/50 ML RTU", "drug_information": { "unit": "50.000000", "type": "UN" }, "code_information": [ { "code": "00338101541", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "OXACILLIN CONTINUOUS INFUSION 2 GM/50 ML RTU", "drug_information": { "unit": "50.000000", "type": "UN" }, "code_information": [ { "code": "00338101541_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "OXACILLIN SODIUM 1 G IJ SOLR", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "25021014610", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "OXACILLIN SODIUM 10 G IV SOLR", "drug_information": { "unit": "100.000000", "type": "UN" }, "code_information": [ { "code": "55150012999", "type": "NDC" } ], "standard_charges": [ { "minimum": 99.16, "maximum": 330.78, "gross_charge": 351.89, "discounted_cash": 193.54, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 204.1, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 192.13, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 281.51, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 298.05, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 102.4, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 168.91, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 210.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 210.43, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 330.78, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 309.66, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 99.16, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 299.11, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 263.92, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 123.97, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 239.29, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 330.78, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 275.53, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 192.13, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 279.75, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 263.92, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 309.66, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 204.1, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 192.13, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "OXACILLIN SODIUM 2 G IJ SOLR", "drug_information": { "unit": "20.000000", "type": "UN" }, "code_information": [ { "code": "64679069901", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "OXALIPLATIN 100 MG/20ML IV SOLN", "drug_information": { "unit": "20.000000", "type": "UN" }, "code_information": [ { "code": "00703398601", "type": "NDC" } ], "standard_charges": [ { "minimum": 76.57, "maximum": 255.41, "gross_charge": 271.71, "discounted_cash": 149.44, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 157.59, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 148.35, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 217.37, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 230.14, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 79.07, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 130.42, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 162.75, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 162.48, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 255.41, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 239.1, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 76.57, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 230.95, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 203.78, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 95.72, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 184.76, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 255.41, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 212.75, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 148.35, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 216.01, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 203.78, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 239.1, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 157.59, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 148.35, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "OXALIPLATIN 50 MG/10ML IV SOLN", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "60505613206", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "OXAZEPAM 10 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00228206710", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.25, "maximum": 7.52, "gross_charge": 8.0, "discounted_cash": 4.4, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.4, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.78, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.33, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.84, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.79, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.25, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.8, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.82, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.44, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.26, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.36, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "OXAZEPAM 15 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00228206910", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.25, "maximum": 7.52, "gross_charge": 8.0, "discounted_cash": 4.4, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.4, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.78, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.33, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.84, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.79, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.25, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.8, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.82, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.44, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.26, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.36, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "OXCARBAZEPINE 150 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687071101", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "OXCARBAZEPINE 300 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687072201", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "OXCARBAZEPINE 300 MG/5ML PO SUSP", "drug_information": { "unit": "250.000000", "type": "UN" }, "code_information": [ { "code": "00781627043", "type": "NDC" } ], "standard_charges": [ { "minimum": 105.31, "maximum": 351.28, "gross_charge": 373.7, "discounted_cash": 205.54, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 216.75, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 204.04, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 298.96, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 316.52, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 108.75, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 179.38, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 223.85, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 223.47, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 351.28, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 328.86, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 105.31, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 317.65, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 280.28, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 131.65, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 254.12, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 351.28, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 292.61, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 204.04, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 297.09, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 280.28, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 328.86, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 216.75, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 204.04, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "OXCARBAZEPINE 600 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687073301", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "OXCARBAZEPINE ER 300 MG PO TB24", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "17772012201", "type": "NDC" } ], "standard_charges": [ { "minimum": 8.0, "maximum": 26.7, "gross_charge": 28.4, "discounted_cash": 15.62, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.47, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.51, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.72, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.05, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.26, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.63, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.01, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.98, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.7, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.99, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.14, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.3, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.01, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.31, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.7, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.24, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.51, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.58, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.3, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.99, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.47, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.51, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "OXCARBAZEPINE ER 600 MG PO TB24", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "17772012301", "type": "NDC" } ], "standard_charges": [ { "minimum": 14.65, "maximum": 48.88, "gross_charge": 52.0, "discounted_cash": 28.6, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.16, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.39, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.6, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 44.04, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.13, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.96, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.15, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.1, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 48.88, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.76, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.65, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 44.2, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.32, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.36, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 48.88, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.72, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.39, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.34, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.76, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.16, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.39, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "OXYBUTYNIN CHLORIDE 5 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687067001", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "OXYBUTYNIN CHLORIDE 5 MG/5ML PO SOLN", "drug_information": { "unit": "2.500000", "type": "UN" }, "code_information": [ { "code": "54838051080", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "OXYBUTYNIN CHLORIDE ER 10 MG PO TB24", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68084061021", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.27, "maximum": 4.24, "gross_charge": 4.51, "discounted_cash": 2.48, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.62, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.46, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.61, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.82, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.31, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.16, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.7, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.7, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.24, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.97, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.83, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.38, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.59, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.07, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.24, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.53, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.46, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.59, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.38, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.97, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.62, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.46, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "OXYBUTYNIN CHLORIDE ER 15 MG PO TB24", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "50268062913", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "OXYBUTYNIN CHLORIDE ER 5 MG PO TB24", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68084048001", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "OXYCODONE HCL 100 MG/5ML PO CONC", "drug_information": { "unit": "30.000000", "type": "UN" }, "code_information": [ { "code": "00121082601", "type": "NDC" } ], "standard_charges": [ { "minimum": 15.32, "maximum": 51.12, "gross_charge": 54.38, "discounted_cash": 29.91, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.54, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.69, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.5, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.06, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.82, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.1, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.57, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.52, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 51.12, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.85, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.32, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.22, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.79, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.16, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.98, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 51.12, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.58, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.69, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.23, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.79, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.85, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.54, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.69, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "OXYCODONE HCL 30 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68084098301", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.25, "maximum": 7.52, "gross_charge": 8.0, "discounted_cash": 4.4, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.4, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.78, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.33, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.84, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.79, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.25, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.8, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.82, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.44, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.26, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.36, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "OXYCODONE HCL 5 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68084035401", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.25, "maximum": 7.52, "gross_charge": 8.0, "discounted_cash": 4.4, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.4, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.78, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.33, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.84, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.79, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.25, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.8, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.82, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.44, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.26, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.36, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "OXYCODONE HCL 5 MG/5ML PO SOLN", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "60687040677", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.25, "maximum": 7.52, "gross_charge": 8.0, "discounted_cash": 4.4, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.4, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.78, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.33, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.84, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.79, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.25, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.8, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.82, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.44, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.26, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.36, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "OXYCODONE HCL ER 10 MG PO T12A", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "59011041020", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.87, "maximum": 9.56, "gross_charge": 10.17, "discounted_cash": 5.59, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.9, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.55, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.14, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.61, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.96, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.88, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.09, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.08, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.56, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.95, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.87, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.64, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.63, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.58, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.92, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.56, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.96, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.55, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.09, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.63, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.95, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.9, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.55, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "OXYCODONE HCL ER 15 MG PO T12A", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "59011041520", "type": "NDC" } ], "standard_charges": [ { "minimum": 4.21, "maximum": 14.05, "gross_charge": 14.95, "discounted_cash": 8.22, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.67, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.16, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.96, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.66, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.35, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.18, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.94, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.05, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.16, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.21, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.71, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.21, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.27, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.17, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.05, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.71, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.16, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.89, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.21, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.16, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.67, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.16, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "OXYCODONE HCL ER 20 MG PO T12A", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "59011042020", "type": "NDC" } ], "standard_charges": [ { "minimum": 5.34, "maximum": 17.8, "gross_charge": 18.94, "discounted_cash": 10.42, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.99, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.34, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.15, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.04, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", 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"additional_payer_notes": "N/A", "standard_charge_dollar": 16.67, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.34, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.1, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.21, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.67, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.88, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.83, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.34, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.06, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.21, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.67, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.99, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.34, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "OXYCODONE HCL ER 40 MG PO T12A", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "1070280501", "type": "NDC" } ], "standard_charges": [ { "minimum": 6.15, "maximum": 20.53, "gross_charge": 21.84, "discounted_cash": 12.01, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.67, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.92, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.47, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.36, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.48, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.08, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.06, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.53, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.22, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.15, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.56, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.38, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.69, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.85, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.53, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.1, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.92, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.36, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.38, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.22, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.67, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.92, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "OXYCODONE HCL ER 80 MG PO T12A", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "59011048020", "type": "NDC" } ], "standard_charges": [ { "minimum": 15.95, "maximum": 53.2, "gross_charge": 56.6, "discounted_cash": 31.13, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.83, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.9, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.28, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.94, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.47, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.17, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.9, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.85, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 53.2, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.81, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.95, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 48.11, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.45, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.94, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.49, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 53.2, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 44.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.9, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.45, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.81, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.83, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.9, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "OXYCODONE-ACETAMINOPHEN 5-325 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00406051262", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.25, "maximum": 7.52, "gross_charge": 8.0, "discounted_cash": 4.4, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.4, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.78, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.33, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.84, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.79, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.25, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.8, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.82, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.44, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.26, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.36, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "OXYMETAZOLINE HCL 0.05 % NA SOLN", "drug_information": { "unit": "15.000000", "type": "UN" }, "code_information": [ { "code": "00904743535", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.28, "maximum": 4.26, "gross_charge": 4.53, "discounted_cash": 2.49, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.63, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.47, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.62, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.84, "standard_charge_percentage": 85.0, "methodology": "percent of 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"methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.99, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.28, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.85, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.6, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.08, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.26, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.55, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.47, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": 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total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "OXYMETAZOLINE HCL 0.05 % NA SOLN 30 ML BOTTLE (BULK CHARGE)", "drug_information": { "unit": "30.000000", "type": "UN" }, "code_information": [ { "code": "46122016510", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "OXYMORPHONE HCL 5 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00054028325", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.25, "maximum": 7.52, "gross_charge": 8.0, "discounted_cash": 4.4, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.4, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.78, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.33, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.84, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.79, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.25, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.8, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.82, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.44, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.26, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.36, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "OXYTOCIN 10 UNIT/ML IJ SOLN", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "63323001211", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "OXYTOCIN 10 UNIT/ML IJ SOLN 1 ML VIAL (BULK CHARGE)", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "63323001211_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "OXYTOCIN 30 UNITS/500 ML DRIP RTU ANES", "drug_information": { "unit": "500.000000", "type": "UN" }, "code_information": [ { "code": "71266510301", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "OXYTOCIN 30 UNITS/500 ML NS RTU", "drug_information": { "unit": "500.000000", "type": "UN" }, "code_information": [ { "code": "71266510301_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "OYSTER CALCIUM 1250 (500 CA) MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00904188361", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "P-mastectomy w/ln removal", "code_information": [ { "code": "19302", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4806.97, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3560.72, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 15872.3, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 28800.54, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4806.97, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 28800.54, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PACLITAXEL 100 MG/16.7ML IV CONC", "drug_information": { "unit": "17.000000", "type": "UN" }, "code_information": [ { "code": "61703034222", "type": "NDC" } ], "standard_charges": [ { "minimum": 42.79, "maximum": 142.75, "gross_charge": 151.86, "discounted_cash": 83.52, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.08, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.92, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 121.49, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 128.63, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 44.19, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 72.89, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 90.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 90.81, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 142.75, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 133.64, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.79, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 129.08, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 113.9, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 53.5, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.26, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 142.75, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 118.91, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.92, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 120.73, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 113.9, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 133.64, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.08, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.92, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PACLITAXEL 30 MG/5ML IV CONC", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "00703321301", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PACLITAXEL 300 MG/50ML IV CONC", "drug_information": { "unit": "50.000000", "type": "UN" }, "code_information": [ { "code": "63323076350", "type": "NDC" } ], "standard_charges": [ { "minimum": 115.5, "maximum": 385.26, "gross_charge": 409.85, "discounted_cash": 225.42, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 237.71, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 223.78, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 327.88, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 347.14, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 119.27, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 196.73, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 245.5, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 245.09, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 385.26, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 360.67, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 115.5, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 348.37, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 307.39, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 144.39, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 278.7, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 385.26, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 320.91, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 223.78, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 325.83, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 307.39, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 360.67, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 237.71, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 223.78, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PACLITAXEL PROTEIN-BOUND PART 100 MG IV SUSR", "drug_information": { "unit": "20.000000", "type": "UN" }, "code_information": [ { "code": "68817013450", "type": "NDC" } ], "standard_charges": [ { "minimum": 7.28, "maximum": 4322.1, "gross_charge": 4597.98, "discounted_cash": 2528.89, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2666.83, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3678.38, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3894.49, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1338.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2207.03, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2754.19, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2749.59, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4322.1, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4046.22, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1295.71, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3908.28, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3448.49, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1619.87, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3126.63, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4322.1, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3600.22, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.83, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3655.39, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3448.49, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4046.22, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2666.83, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "PACLITAXEL PROTEIN-BOUND PARTICLE CHEMO INFUSION", "drug_information": { "unit": "20.000000", "type": "UN" }, "code_information": [ { "code": "68817013450_3", "type": "NDC" } ], "standard_charges": [ { "minimum": 7.28, "maximum": 4387.9, "gross_charge": 4667.98, "discounted_cash": 2567.39, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2707.43, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3734.38, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3953.78, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1358.38, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2240.63, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2796.12, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2791.45, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4387.9, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4107.82, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", 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"standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4107.82, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2707.43, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "PACLITAXEL PROTEIN-BOUND PARTICLE CHEMO INFUSION|DISCARDED DRUG NOT ADMINISTERED", "drug_information": { "unit": "20.000000", "type": "UN" }, "code_information": [ { "code": "68817013450_2", "type": "NDC" } ], "standard_charges": [ { 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schedule" } ], "additional_generic_notes": "" } ] }, { "description": "PALIFERMIN 5.16 MG IV SOLR", "drug_information": { "unit": "1.040000", "type": "UN" }, "code_information": [ { "code": "66658011306_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 18.56, "maximum": 18688.76, "gross_charge": 19881.66, "discounted_cash": 10934.91, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 11531.36, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15905.33, "standard_charge_percentage": 80.0, 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"plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14911.25, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 7004.31, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 13519.53, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 18688.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 15567.34, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.05, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 15189.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14911.25, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17495.86, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 11531.36, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "PALIFERMIN 5.16 MG IV SOLR|DISCARDED DRUG NOT ADMINISTERED", "drug_information": { "unit": "1.040000", "type": "UN" }, "code_information": [ { "code": "66658011306", "type": "NDC" } ], "standard_charges": [ { "minimum": 18.56, "maximum": 9344.38, "gross_charge": 9940.83, "discounted_cash": 5467.46, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5765.68, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7952.66, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8419.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2892.78, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4771.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": 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"methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8449.71, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7455.62, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3502.15, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6759.76, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 9344.38, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7783.67, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.05, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7902.96, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7455.62, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8747.93, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5765.68, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "PALIPERIDONE ER 6 MG PO TB24", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687047001", "type": "NDC" } ], "standard_charges": [ { "minimum": 5.0, "maximum": 16.69, "gross_charge": 17.75, "discounted_cash": 9.76, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.3, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.69, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.03, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.17, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.52, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.63, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.61, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.69, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.62, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.09, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.31, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.25, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.07, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.69, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.9, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.69, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.11, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.31, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.62, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.3, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.69, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PALIPERIDONE ER 9 MG PO TB24", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "50458055201", "type": "NDC" } ], "standard_charges": [ { "minimum": 12.56, "maximum": 41.91, "gross_charge": 44.58, "discounted_cash": 24.52, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.86, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.34, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.66, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.76, 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"standard_charge_dollar": 24.34, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PALIPERIDONE PALMITATE ER 117 MG/0.75ML IM SUSY", "drug_information": { "unit": "0.750000", "type": "UN" }, "code_information": [ { "code": "50458056201", "type": "NDC" } ], "standard_charges": [ { "minimum": 1397.79, "maximum": 4662.62, "gross_charge": 4960.23, "discounted_cash": 2728.13, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2876.93, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2708.29, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3968.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4201.31, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1443.43, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2380.91, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2971.18, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2966.22, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4662.62, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4365.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1397.79, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4216.2, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3720.17, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1747.49, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3372.96, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4662.62, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": 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billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2876.93, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2708.29, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PALIPERIDONE PALMITATE ER 156 MG/ML IM SUSY", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "50458056301", "type": "NDC" } ], "standard_charges": [ { "minimum": 1863.79, "maximum": 6217.06, "gross_charge": 6613.89, "discounted_cash": 3637.64, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3836.06, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3611.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5291.11, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5601.96, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1924.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3174.67, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3961.72, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 3955.11, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6217.06, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5820.22, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1863.79, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5621.81, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4960.42, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2330.07, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4497.45, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6217.06, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5178.68, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3611.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5258.04, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4960.42, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5820.22, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3836.06, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3611.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PALIPERIDONE PALMITATE ER 234 MG/1.5ML IM SUSY", "drug_information": { "unit": "1.500000", "type": "UN" }, "code_information": [ { "code": "50458056401", "type": "NDC" } ], "standard_charges": [ { "minimum": 8.06, "maximum": 9325.35, "gross_charge": 9920.58, "discounted_cash": 5456.32, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5753.94, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.06, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7936.46, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8402.73, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2886.89, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4761.88, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5942.43, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 5932.51, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9325.35, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8730.11, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2795.62, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8432.49, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7440.44, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3495.02, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6745.99, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 9325.35, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7767.81, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.88, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7886.86, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7440.44, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8730.11, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5753.94, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.06, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "PALIVIZUMAB 100 MG/ML IM SOLN", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "66658023101", "type": "NDC" } ], "standard_charges": [ { "minimum": 393.05, "maximum": 9694.93, "gross_charge": 10313.76, "discounted_cash": 5672.57, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5981.98, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 393.05, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8251.01, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8735.75, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3001.3, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4950.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6177.94, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 6167.63, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9694.93, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9076.11, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2906.42, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8766.7, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7735.32, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3633.54, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7013.36, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 9694.93, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8075.67, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 530.62, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 8199.44, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7735.32, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9076.11, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5981.98, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 393.05, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "PALIVIZUMAB 50 MG/0.5ML IM SOLN", "drug_information": { "unit": "0.500000", "type": "UN" }, "code_information": [ { "code": "66658023001", "type": "NDC" } ], "standard_charges": [ { "minimum": 393.05, "maximum": 5134.26, "gross_charge": 5461.98, "discounted_cash": 3004.09, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3167.95, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 393.05, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4369.58, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4626.3, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1589.44, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2621.75, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3271.73, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 3266.26, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5134.26, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4806.54, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1539.19, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4642.68, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4096.49, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1924.26, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3714.15, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5134.26, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4276.73, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 530.62, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4342.27, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4096.49, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4806.54, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3167.95, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 393.05, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "PALONOSETRON HCL 0.25 MG/5ML IV SOLN", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "60505619301", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PAMIDRONATE DISODIUM 30 MG/10ML IV SOLN", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "67457043010", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PAMIDRONATE DISODIUM 6 MG/ML IV SOLN", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "61703032518", "type": "NDC" } ], "standard_charges": [ { "minimum": 23.34, "maximum": 77.86, "gross_charge": 82.83, "discounted_cash": 45.56, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 48.04, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.23, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 66.26, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 70.16, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.1, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.76, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.62, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.53, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 77.86, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 72.89, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.34, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 70.41, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 62.12, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.18, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 56.32, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 77.86, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 64.86, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.23, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.85, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 62.12, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 72.89, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 48.04, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.23, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PANCRELIPASE (LIP-PROT-AMYL) 10440-39150 UNITS PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "73562010410", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.7, "maximum": 9.0, "gross_charge": 9.57, "discounted_cash": 5.26, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.55, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.23, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.66, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.11, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.78, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.59, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.73, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.72, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.42, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.7, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.13, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.18, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.37, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.51, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.49, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.23, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.61, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.18, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.42, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.55, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.23, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PANCRELIPASE (LIP-PROT-AMYL) 20880-78300 UNITS PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "73562020810", "type": "NDC" } ], "standard_charges": [ { "minimum": 5.32, "maximum": 17.74, "gross_charge": 18.87, "discounted_cash": 10.38, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.94, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.3, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.1, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.98, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.49, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.06, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.3, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.28, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.74, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.61, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.32, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.04, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.15, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.65, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.83, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.74, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.78, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.3, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.15, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.61, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.94, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.3, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PANCRELIPASE (LIP-PROT-AMYL) 3000-9500 UNITS PO CPEP", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00032004570", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PANCRELIPASE (LIP-PROT-AMYL) 6000-19000 UNITS PO CPEP", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00032004670", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.33, "maximum": 4.43, "gross_charge": 4.71, "discounted_cash": 2.59, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.73, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.77, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.99, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.37, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.26, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.82, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.82, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.43, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.14, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.33, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.53, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.66, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.43, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.69, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.74, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.53, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.14, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.73, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PANITUMUMAB 100 MG/5ML IV SOLN", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "55513095401", "type": "NDC" } ], "standard_charges": [ { "minimum": 1414.74, "maximum": 4719.16, "gross_charge": 5020.38, "discounted_cash": 2761.21, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2911.82, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2741.13, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4016.3, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4252.26, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1460.93, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2409.78, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3007.21, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 3002.19, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4719.16, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4417.93, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1414.74, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4267.32, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3765.29, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1768.68, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3413.86, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4719.16, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3930.96, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2741.13, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3991.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3765.29, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4417.93, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2911.82, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2741.13, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PANTOPRAZOLE 2 MG/ML ORAL SUSPENSION", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "0008060701", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PANTOPRAZOLE SODIUM 20 MG PO TBEC", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687072501", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PANTOPRAZOLE SODIUM 40 MG IV SOLR", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "71288060011", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PANTOPRAZOLE SODIUM 40 MG PO TBEC", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687073609", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PANTOPRAZOLE SODIUM-NACL 80-0.9 MG/100ML-% IV SOLN", "drug_information": { "unit": "100.000000", "type": "UN" }, "code_information": [ { "code": "00338964812", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PAPAVERINE HCL 30 MG/ML IJ SOLN", "drug_information": { "unit": "2.000000", "type": "UN" }, "code_information": [ { "code": "54288014210", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PAPAYA ENZYMES PO CHEW", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "4009310513", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PARAGARD INTRAUTERINE COPPER IU IUD", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "59365512801", "type": "NDC" } ], "standard_charges": [ { "minimum": 611.51, "maximum": 2039.8, "gross_charge": 2170.0, "discounted_cash": 1193.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1258.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1184.82, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1736.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1837.99, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 631.47, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1041.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1299.83, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 1297.66, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2039.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1909.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 611.51, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1844.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1627.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 764.49, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1475.6, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2039.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1699.11, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1184.82, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1725.15, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1627.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1909.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1258.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1184.82, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PARICALCITOL 2 MCG/ML IV SOLN", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00074463701", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PARICALCITOL 5 MCG/ML IV SOLN", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00074165801", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PAROXETINE HCL 10 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "50268064015", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PAROXETINE HCL 10 MG/5ML PO SUSP", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "70954031910", "type": "NDC" } ], "standard_charges": [ { "minimum": 4.03, "maximum": 13.43, "gross_charge": 14.29, "discounted_cash": 7.86, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.29, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.8, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.43, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.1, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.86, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.56, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.55, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.43, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.58, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.03, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.15, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.72, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.03, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.43, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.19, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.8, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.36, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.72, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.58, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.29, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.8, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PAROXETINE HCL 20 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68084004501", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PAROXETINE HCL 30 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68084004601", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PAROXETINE HCL 40 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "50268064315", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Part removal of ankle/heel", "code_information": [ { "code": "28120", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2391.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1771.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 15456.84, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 28046.7, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2391.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 28046.7, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Part removal of metatarsal", "code_information": [ { "code": "28110", "type": "HCPCS" }, { "code": "28112", "type": "HCPCS" }, { "code": "28113", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2391.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1771.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 9385.21, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 17029.6, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2391.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 17029.6, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Part remove hip bone super", "code_information": [ { "code": "27070", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 12248.72, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 22225.5, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 22225.5, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Partial amputation of toe", "code_information": [ { "code": "28825", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2391.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1771.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 8954.78, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 16248.6, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2391.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 16248.6, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Partial exc bone humerus", "code_information": [ { "code": "24140", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2391.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1771.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 12397.15, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 22502.65, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2391.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 22502.65, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Partial excision of lip", "code_information": [ { "code": "40510", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2390.47, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1770.72, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 3812.36, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 6917.58, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2390.47, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 6917.58, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Partial hysterectomy", "code_information": [ { "code": "58180", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 29307.23, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 53290.61, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 53290.61, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Partial mastectomy", "code_information": [ { "code": "19301", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2822.56, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2090.79, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 13483.24, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 24465.56, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2822.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 24465.56, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Partial removal collar bone", "code_information": [ { "code": "23120", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2391.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1771.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 12709.84, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 23094.06, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2391.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 23094.06, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Partial removal finger bone", "code_information": [ { "code": "26235", "type": "HCPCS" }, { "code": "26236", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1179.66, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 873.82, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 5351.34, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 9710.1, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1179.66, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 9710.1, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Partial removal foot fascia", "code_information": [ { "code": "28060", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2391.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1771.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 10946.61, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 19862.79, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2391.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 19862.79, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Partial removal leg bone(s)", "code_information": [ { "code": "27360", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2391.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1771.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 11094.97, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 20132.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2391.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 20132.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Partial removal of eye fluid", "code_information": [ { "code": "67005", "type": "HCPCS" }, { "code": "67010", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1681.13, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1245.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 7810.25, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 14171.84, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1681.13, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 14171.84, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Partial removal of foot bone", "code_information": [ { "code": "28122", "type": "HCPCS" }, { "code": "28288", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2391.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1771.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 7911.21, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 14355.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2391.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 14355.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Partial removal of hand bone", "code_information": [ { "code": "26230", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2391.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1771.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 6101.3, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 11070.9, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2391.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 11070.9, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Partial removal of hymen", "code_information": [ { "code": "56700", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2343.63, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1736.02, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 6975.07, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 12656.38, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2343.63, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 12656.38, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Partial removal of larynx", "code_information": [ { "code": "31375", "type": "HCPCS" }, { "code": "31380", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 19675.3, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 35701.16, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 35701.16, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Partial removal of lip", "code_information": [ { "code": "40530", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2390.47, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1770.72, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 6034.44, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 10949.58, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2390.47, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 10949.58, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Partial removal of nose", "code_information": [ { "code": "30150", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4360.43, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3229.95, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 28838.99, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 52328.88, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4360.43, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 52328.88, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Partial removal of penis", "code_information": [ { "code": "54120", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2542.24, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1883.14, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 8606.2, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 15616.08, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2542.24, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 15616.08, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Partial removal of radius", "code_information": [ { "code": "25230", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2391.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1771.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 8061.48, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 14627.7, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2391.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 14627.7, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Partial removal of rib", "code_information": [ { "code": "21600", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 5265.64, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3900.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 20029.1, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 36699.01, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5265.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 36699.01, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Partial removal of scapula", "code_information": [ { "code": "23190", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2391.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1771.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 13789.43, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 26291.03, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2391.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 26291.03, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Partial removal of sternum", "code_information": [ { "code": "21620", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 16127.52, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 29263.64, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 29263.64, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Partial removal of thyroid", "code_information": [ { "code": "60220", "type": "HCPCS" }, { "code": "60225", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4300.51, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3185.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 11011.29, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 22635.72, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4300.51, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 22635.72, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Partial removal of tibia", "code_information": [ { "code": "27640", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2391.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1771.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 7489.6, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 13958.68, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2391.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 13958.68, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Partial removal of toe", "code_information": [ { "code": "28124", "type": "HCPCS" }, { "code": "28126", "type": "HCPCS" }, { "code": "28160", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2391.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1771.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 5180.22, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 9399.6, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2391.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 9399.6, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Partial removal of tongue", "code_information": [ { "code": "41120", "type": "HCPCS" }, { "code": "41130", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4360.43, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3229.95, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 21732.34, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 39433.68, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4360.43, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 39433.68, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Partial removal of ulna", "code_information": [ { "code": "25150", "type": "HCPCS" }, { "code": "25240", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2391.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1771.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 28081.94, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 50955.12, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2391.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 50955.12, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Partial removal of vulva", "code_information": [ { "code": "56620", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2343.63, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1736.02, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 8457.79, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 15346.8, "methodology": "percent of total billed charges" }, { 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"N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 12690.16, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 24211.48, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4300.51, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 24211.48, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PATIROMER SORBITEX CALCIUM 16.8 G PO PACK", "drug_information": { "unit": "1.000000", "type": "UN" }, 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"standard_charge_dollar": 47.82, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.43, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.1, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.82, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.76, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 53.07, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.68, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.91, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.99, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.35, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.89, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.39, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 53.07, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 44.21, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.83, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 44.89, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.35, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.68, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.75, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.83, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PATIROMER SORBITEX CALCIUM 25.2 G PO PACK", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "53436025230", "type": "NDC" } ], "standard_charges": [ { "minimum": 15.91, "maximum": 53.07, "gross_charge": 56.46, "discounted_cash": 31.05, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.75, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.83, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.17, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.82, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.43, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.1, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.82, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.76, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 53.07, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.68, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.91, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.99, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.35, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.89, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.39, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 53.07, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 44.21, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.83, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 44.89, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.35, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.68, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.75, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.83, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PATIROMER SORBITEX CALCIUM 8.4 G PO PACK", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "53436008430", "type": "NDC" } ], "standard_charges": [ { "minimum": 15.91, "maximum": 53.07, "gross_charge": 56.46, "discounted_cash": 31.05, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.75, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.83, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.17, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.82, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.43, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.1, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.82, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.76, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 53.07, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.68, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.91, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.99, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.35, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.89, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.39, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 53.07, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 44.21, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.83, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 44.89, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.35, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.68, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.75, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.83, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PB-HYOSCY-ATROPINE-SCOPOLAMINE 16.2 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "50742066701", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PB-HYOSCY-ATROPINE-SCOPOLAMINE 16.2 MG/5ML PO ELIX", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "66689006310", "type": "NDC" } ], "standard_charges": [ { "minimum": 20.73, "maximum": 69.16, "gross_charge": 73.57, "discounted_cash": 40.46, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.67, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.17, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 58.86, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 62.31, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.41, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.31, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 44.07, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.99, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 69.16, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 64.74, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.73, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 62.53, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.18, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.92, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.03, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 69.16, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 57.61, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.17, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 58.49, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.18, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 64.74, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.67, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.17, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PCEA FENTANYL CIT-ROPIVACAINE-NACL 0.4-0.1-0.9 MG/200ML-% EP SOLN", "drug_information": { "unit": "200.000000", "type": "UN" }, "code_information": [ { "code": "70092120737", "type": "NDC" } ], "standard_charges": [ { "minimum": 36.25, "maximum": 120.93, "gross_charge": 128.65, "discounted_cash": 70.76, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.62, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 70.24, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 102.92, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 108.97, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.44, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.75, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 77.06, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 76.93, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 120.93, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 113.21, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.25, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 109.35, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.49, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.32, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.48, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 120.93, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 100.73, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 70.24, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 102.28, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.49, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 113.21, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.62, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 70.24, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Pedcle fh/ch/ch/m/n/ax/g/h/f", "code_information": [ { "code": "15574", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1348.33, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 998.76, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 20357.71, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 36939.43, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1348.33, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 36939.43, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PEDIATRIC TPN FEE (RX USE ONLY)", "drug_information": { "unit": "1000.000000", "type": "UN" }, "code_information": [ { "code": "9997088402", "type": "NDC" } ], "standard_charges": [ { "minimum": 140.9, "maximum": 1158.0, "gross_charge": 500.0, "discounted_cash": 275.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 290.0, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 273.0, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 434.0, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 145.5, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 240.0, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 299.5, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 299.0, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 470.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 440.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 140.9, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 425.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 375.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 176.15, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 340.0, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 470.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 391.5, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 273.0, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 397.5, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 375.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 440.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 290.0, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 273.0, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Pedicle e/n/e/l/ntroral", "code_information": [ { "code": "15576", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1348.33, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 998.76, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 7993.64, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 14504.58, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1348.33, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 14504.58, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PEG 3350-KCL-NA BICARB-NACL 420 G PO SOLR", "drug_information": { "unit": "4000.000000", "type": "UN" }, "code_information": [ { "code": "10572030201", "type": "NDC" } ], "standard_charges": [ { "minimum": 14.86, "maximum": 49.59, "gross_charge": 52.75, "discounted_cash": 29.01, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.8, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 44.68, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.35, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.32, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.6, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.54, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.59, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.42, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.86, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 44.84, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.56, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.58, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.87, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.59, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.3, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.8, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.94, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.56, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.42, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.8, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PEG 3350-KCL-NABCB-NACL-NASULF 236 G PO SOLR", "drug_information": { "unit": "4000.000000", "type": "UN" }, "code_information": [ { "code": "10572010001", "type": "NDC" } ], "standard_charges": [ { "minimum": 12.51, "maximum": 41.72, "gross_charge": 44.38, "discounted_cash": 24.41, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.74, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.23, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.5, "standard_charge_percentage": 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"PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.29, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.64, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.18, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.72, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.75, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.23, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.28, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.29, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.05, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.74, 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"plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 239.0, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 238.6, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 375.06, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 351.12, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 112.44, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 339.15, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 299.25, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 140.57, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 271.32, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 375.06, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 312.42, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 217.85, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 317.21, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 299.25, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": 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"standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 26785.99, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 33426.68, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 11394.0, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52455.89, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 49107.64, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 15725.61, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 47433.52, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 41853.11, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 19659.8, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37946.82, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 52455.89, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 43694.64, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 19953.69, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 15189.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 41853.11, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 49107.64, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 32366.4, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 14780.51, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "PEGASPARGASE SYRINGE", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "72694095401_3", "type": "NDC" } ], "standard_charges": [ { "minimum": 11394.0, "maximum": 52521.69, "gross_charge": 55874.14, "discounted_cash": 30730.78, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 32407.0, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 14780.51, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 44699.31, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": 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85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10115.89, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 4751.77, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 9171.74, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 12678.58, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 10560.99, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7364.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 10722.84, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10115.89, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11869.31, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7822.95, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7364.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PEGFILGRASTIM-APGF 6 MG/0.6ML SC SOSY", "drug_information": { "unit": "0.600000", "type": "UN" }, "code_information": [ { "code": "00069032401", "type": "NDC" } ], "standard_charges": [ { "minimum": 52.72, "maximum": 4647.81, "gross_charge": 4944.48, "discounted_cash": 2719.46, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2867.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.72, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3955.58, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4187.97, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1438.84, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2373.35, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2961.74, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2956.8, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4647.81, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4351.14, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1393.35, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4202.81, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3708.36, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1741.94, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3362.25, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4647.81, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3871.53, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 71.17, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3930.86, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3708.36, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4351.14, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2867.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.72, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "PEGFILGRASTIM-BMEZ 6 MG/0.6ML SC SOSY", "drug_information": { "unit": "0.600000", "type": "UN" }, "code_information": [ { "code": "61314086601", "type": "NDC" } ], "standard_charges": [ { "minimum": 189.33, "maximum": 10737.91, "gross_charge": 11423.31, "discounted_cash": 6282.82, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 6625.52, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 189.33, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9138.65, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9675.54, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3324.18, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5483.19, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6842.56, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 6831.14, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10737.91, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10052.51, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3219.09, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9709.81, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8567.48, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 4024.43, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7767.85, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 10737.91, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8944.45, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 255.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 9081.53, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8567.48, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10052.51, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6625.52, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 189.33, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "PEGFILGRASTIM-CBQV (INF DEV) 6 MG/0.6ML SC SOSY", "drug_information": { "unit": "0.600000", "type": "UN" }, "code_information": [ { "code": "70114013001", "type": "NDC" } ], "standard_charges": [ { "minimum": 78.29, "maximum": 9297.62, "gross_charge": 9891.09, "discounted_cash": 5440.1, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5736.83, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 78.29, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7912.87, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8377.75, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2878.31, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4747.72, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5924.76, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 5914.87, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9297.62, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8704.16, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2787.31, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8407.43, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7418.32, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3484.63, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6725.94, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 9297.62, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7744.72, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 105.69, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7863.42, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7418.32, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8704.16, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5736.83, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 78.29, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "PEGFILGRASTIM-CBQV 6 MG/0.6ML SC SOSY", "drug_information": { "unit": "0.600000", "type": "UN" }, "code_information": [ { "code": "70114010101", "type": "NDC" } ], "standard_charges": [ { "minimum": 78.29, "maximum": 4650.18, "gross_charge": 4947.0, "discounted_cash": 2720.85, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2869.26, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 78.29, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3957.6, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4190.11, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1439.58, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2374.56, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2963.25, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2958.31, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4650.18, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4353.36, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1394.06, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4204.95, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3710.25, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1742.83, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3363.96, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4650.18, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3873.5, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 105.69, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3932.87, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3710.25, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4353.36, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2869.26, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 78.29, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "PEGFILGRASTIM-JMDB 6 MG/0.6ML SC SOSY", "drug_information": { "unit": "0.600000", "type": "UN" }, "code_information": [ { "code": "83257000541", "type": "NDC" } ], "standard_charges": [ { "minimum": 74.0, "maximum": 4923.72, "gross_charge": 5238.0, "discounted_cash": 2880.9, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3038.04, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.0, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4190.4, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4436.59, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1524.26, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2514.24, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3137.56, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 3132.32, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4923.72, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4609.44, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1476.07, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4452.3, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3928.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1845.35, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3561.84, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4923.72, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4101.35, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 99.9, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4164.21, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3928.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4609.44, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3038.04, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.0, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "PEGLOTICASE 8 MG/ML IV SOLN", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "75987008010", "type": "NDC" } ], "standard_charges": [ { "minimum": 1901.25, "maximum": 63737.64, "gross_charge": 67806.0, "discounted_cash": 37293.3, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 39327.48, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1901.25, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 54244.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 57431.68, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19731.55, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32546.88, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 40615.79, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 11394.0, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 63737.64, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 59669.28, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 19107.73, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 57635.1, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 50854.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 23888.05, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 46108.08, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 63737.64, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 53092.1, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2566.69, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 15189.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 50854.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 59669.28, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 39327.48, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1901.25, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "Pelvic examination", "code_information": [ { "code": "57410", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2343.63, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1736.02, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 5584.96, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 10134.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2343.63, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 10134.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PEMBROLIZUMAB 100 MG/4ML IV SOLN", "drug_information": { "unit": "4.000000", "type": "UN" }, "code_information": [ { "code": "00006302602", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.79, "maximum": 16305.47, "gross_charge": 17346.24, "discounted_cash": 9540.43, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 10060.82, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.79, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13876.99, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14692.27, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5047.76, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8326.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 10390.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 10373.05, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16305.47, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15264.69, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 4888.17, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14744.3, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13009.68, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 6111.08, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 11795.44, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 16305.47, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 13582.11, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.91, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 13790.26, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13009.68, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15264.69, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 10060.82, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.79, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "PEMETREXED DISODIUM 100 MG IV SOLR", "drug_information": { "unit": "4.000000", "type": "UN" }, "code_information": [ { "code": "43598038662_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.28, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.08, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "PEMETREXED DISODIUM 100 MG IV SOLR|DISCARDED DRUG NOT ADMINISTERED", "drug_information": { "unit": "4.000000", "type": "UN" }, "code_information": [ { "code": "43598038662", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.28, "maximum": 31.94, "gross_charge": 33.98, "discounted_cash": 18.69, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.71, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.78, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.89, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.31, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.35, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.32, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.94, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.9, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.58, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.49, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.97, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.11, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.94, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.61, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.08, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.01, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.49, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.9, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.71, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "PEMETREXED DISODIUM 500 MG IV SOLR", "drug_information": { "unit": "20.000000", "type": "UN" }, "code_information": [ { "code": "00002762301", "type": "NDC" } ], "standard_charges": [ { "minimum": 3095.64, "maximum": 10326.14, "gross_charge": 10985.25, "discounted_cash": 6041.89, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 6371.45, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5997.95, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8788.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9304.51, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3196.71, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5272.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6580.16, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 6569.18, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10326.14, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9667.02, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3095.64, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9337.46, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8238.94, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3870.1, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7469.97, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 10326.14, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8601.45, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5997.95, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 8733.27, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8238.94, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9667.02, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6371.45, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5997.95, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PEMIVIBART 500 MG/4ML IV SOLN", "drug_information": { "unit": "4.000000", "type": "UN" }, "code_information": [ { "code": "81960003103", "type": "NDC" } ], "standard_charges": [ { "minimum": 723.29, "maximum": 2412.67, "gross_charge": 2566.67, "discounted_cash": 1411.67, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1488.67, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1401.4, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2053.34, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2173.97, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 746.9, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1232.0, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1537.44, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 1534.87, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2412.67, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2258.67, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 723.29, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2181.67, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1925.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 904.24, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1745.34, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2412.67, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2009.7, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1401.4, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2040.5, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1925.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2258.67, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1488.67, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1401.4, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PENICILLAMINE 250 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00037440101", "type": "NDC" } ], "standard_charges": [ { "minimum": 49.72, "maximum": 165.83, "gross_charge": 176.42, "discounted_cash": 97.03, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 102.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.33, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 141.14, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 149.43, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 51.34, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 84.68, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 105.68, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 105.5, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 165.83, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 155.25, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.72, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 149.96, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 132.32, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 62.15, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 119.97, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 165.83, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 138.14, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.33, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 140.25, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 132.32, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 155.25, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 102.32, "standard_charge_percentage": 58.0, "methodology": 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of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 311.34, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 939.1, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 828.62, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 389.23, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 751.28, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1038.53, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 865.07, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.96, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 878.33, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": 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"60793070210", "type": "NDC" } ], "standard_charges": [ { "minimum": 638.01, "maximum": 2128.22, "gross_charge": 2264.06, "discounted_cash": 1245.23, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1313.15, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1236.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1811.25, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1917.66, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 658.84, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1086.75, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1356.17, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 1353.91, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2128.22, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1992.37, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 638.01, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1924.45, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1698.05, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 797.63, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1539.56, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2128.22, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1772.76, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1236.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1799.93, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1698.05, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1992.37, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1313.15, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", 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Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 446.51, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 472.74, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 162.42, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 267.91, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 334.33, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 333.77, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 524.65, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 491.16, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 157.28, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 474.42, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 418.61, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 196.63, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 379.54, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 524.65, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 437.02, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.96, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 443.72, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 418.61, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 491.16, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 323.72, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.31, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "PENICILLIN G POT IN DEXTROSE 60000 UNIT/ML IV SOLN", "drug_information": { "unit": "50.000000", "type": "UN" }, "code_information": [ { "code": "00338102541", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PENICILLIN G POTASSIUM 20000000 UNITS IJ SOLR", "drug_information": { "unit": "40.000000", "type": "UN" }, "code_information": [ { "code": "00781613694", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PENICILLIN G POTASSIUM 500000 UNITS/ML SYRINGE", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "C0049052083", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PENICILLIN G POTASSIUM 5000000 UNITS IJ SOLR", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "44567031110", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PENICILLIN G SODIUM 5000000 UNITS IJ SOLR", "drug_information": { "unit": "1.200000", "type": "UN" }, "code_information": [ { "code": "00781615395", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 1158.0, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.72, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PENICILLIN V POTASSIUM 250 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "1671423401", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PENICILLIN V POTASSIUM 250 MG/5ML PO SOLR", "drug_information": { "unit": "100.000000", "type": "UN" }, "code_information": [ { "code": "00093412773", "type": "NDC" } ], "standard_charges": [ { "minimum": 4.86, "maximum": 16.22, "gross_charge": 17.25, "discounted_cash": 9.49, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.01, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.42, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.61, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.02, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.28, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.33, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.32, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.22, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.18, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.86, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.66, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.94, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.08, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.73, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.22, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.51, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.42, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.71, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.94, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.18, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.01, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.42, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Penile injection", "code_information": [ { "code": "54235", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 179.27, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 132.79, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 23426.74, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 42508.2, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 179.27, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 42508.2, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Penis plastic surgery", "code_information": [ { "code": "54360", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2542.24, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1883.14, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 12184.78, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 22109.48, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2542.24, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 22109.48, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PENTAFLUOROPROP-TETRAFLUOROETH EX AERO", "drug_information": { "unit": "116.000000", "type": "UN" }, "code_information": [ { "code": "00386000404", "type": "NDC" } ], "standard_charges": [ { "minimum": 21.74, "maximum": 72.5, "gross_charge": 77.13, "discounted_cash": 42.42, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 44.74, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.11, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.7, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.33, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.44, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.02, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.2, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.12, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 72.5, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 67.87, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.74, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.56, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 57.85, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.17, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.45, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 72.5, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.39, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.11, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.32, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 57.85, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 67.87, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 44.74, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.11, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PENTAMIDINE IM SYRINGE", "drug_information": { "unit": "3.000000", "type": "UN" }, "code_information": [ { "code": "13925051510", "type": "NDC" } ], "standard_charges": [ { "minimum": 129.08, "maximum": 1158.0, "gross_charge": 458.06, "discounted_cash": 251.93, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 265.67, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 250.1, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 397.6, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 133.3, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 219.87, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 274.38, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 273.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 430.58, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 403.09, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 129.08, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 389.35, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 343.55, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 161.37, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 311.48, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 430.58, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 358.66, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 250.1, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 364.16, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 343.55, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 403.09, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 265.67, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 250.1, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PENTAMIDINE ISETHIONATE 300 MG IJ SOLR", "drug_information": { "unit": "3.000000", "type": "UN" }, "code_information": [ { "code": "13925051510_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 129.08, "maximum": 1158.0, "gross_charge": 458.06, "discounted_cash": 251.93, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 265.67, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 250.1, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 397.6, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 133.3, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 219.87, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 274.38, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 273.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 430.58, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 403.09, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 129.08, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 389.35, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 343.55, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 161.37, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 311.48, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 430.58, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 358.66, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 250.1, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 364.16, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 343.55, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 403.09, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 265.67, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 250.1, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PENTAMIDINE ISETHIONATE 300 MG IN SOLR", "drug_information": { "unit": "6.000000", "type": "UN" }, "code_information": [ { "code": "63323087715", "type": "NDC" } ], "standard_charges": [ { "minimum": 74.18, "maximum": 247.43, "gross_charge": 263.22, "discounted_cash": 144.77, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 152.67, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 143.72, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 210.58, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 222.95, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 76.6, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 126.35, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 157.67, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 157.41, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 247.43, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 231.63, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.18, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 223.74, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 197.42, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 92.73, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 178.99, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 247.43, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 206.1, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 143.72, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 209.26, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 197.42, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 231.63, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 152.67, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 143.72, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PENTOBARBITAL SODIUM 50 MG/ML IJ SOLN", "drug_information": { "unit": "50.000000", "type": "UN" }, "code_information": [ { "code": "24201001050", "type": "NDC" } ], "standard_charges": [ { "minimum": 638.07, "maximum": 2128.4, "gross_charge": 2264.25, "discounted_cash": 1245.34, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1313.27, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1236.28, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1811.4, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1917.82, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 658.9, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1086.84, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1356.29, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 1354.02, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2128.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1992.54, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 638.07, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1924.61, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1698.19, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 797.7, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1539.69, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2128.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1772.91, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1236.28, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1800.08, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1698.19, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1992.54, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1313.27, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1236.28, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PENTOSAN POLYSULFATE SODIUM 100 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "50458009801", "type": "NDC" } ], "standard_charges": [ { "minimum": 7.21, "maximum": 24.05, "gross_charge": 25.58, "discounted_cash": 14.07, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.84, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.97, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.46, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.67, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.44, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.28, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.32, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.3, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.05, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.51, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.21, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.74, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.19, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.01, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.39, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.05, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.03, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.97, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.34, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.19, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.51, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.84, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.97, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PENTOSTATIN 10 MG IV SOLR", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "00409080101", "type": "NDC" } ], "standard_charges": [ { "minimum": 1387.81, "maximum": 6493.78, "gross_charge": 6908.28, "discounted_cash": 3799.55, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4006.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1387.81, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5526.62, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5851.31, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2010.31, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3315.97, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4138.06, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4131.15, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6493.78, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6079.29, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1946.75, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5872.04, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5181.21, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2433.79, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4697.63, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6493.78, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5409.18, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1873.54, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5492.08, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5181.21, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6079.29, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4006.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1387.81, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "PENTOXIFYLLINE 20 MG/ML ORAL SUSPENSION", "drug_information": { "unit": "20.000000", "type": "UN" }, "code_information": [ { "code": "08252000022", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.48, "maximum": 4.94, "gross_charge": 5.25, "discounted_cash": 2.89, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.05, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.87, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.45, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.53, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.52, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.14, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.14, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.94, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.62, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.48, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.46, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.94, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.85, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.57, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.94, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.11, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.87, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.17, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.94, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.62, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.05, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.87, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PENTOXIFYLLINE ER 400 MG PO TBCR", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00904544861", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PERAMPANEL 0.5 MG/ML PO SUSP", "drug_information": { "unit": "4.000000", "type": "UN" }, "code_information": [ { "code": "69616029038", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.9, "maximum": 39.69, "gross_charge": 42.22, "discounted_cash": 23.22, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.49, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.05, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.78, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.76, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.29, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.27, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.29, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.25, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.69, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.15, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.9, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.89, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.67, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.87, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.71, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.69, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.06, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.05, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.56, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.67, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.15, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.49, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.05, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Perc cryo ablate renal tum", "code_information": [ { "code": "50593", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 7674.11, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5684.53, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 20523.99, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 37241.1, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7674.11, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 37241.1, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Perc d-e cor revasc chro sin", "code_information": [ { "code": "C9607", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 13235.9, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 9804.37, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 18040.91, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 32735.53, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 13235.9, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 32735.53, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Perc d-e cor revasc t cabg s", "code_information": [ { "code": "C9604", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 8359.13, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 6191.95, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 19751.44, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 35839.33, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8359.13, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 35839.33, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Perc d-e cor stent ather s", "code_information": [ { "code": "C9602", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 13235.9, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 9804.37, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 33256.07, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 60343.67, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 13235.9, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 60343.67, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Perc drug-el cor stent sing", "code_information": [ { "code": "C9600", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 8359.13, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 6191.95, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 17834.41, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 32360.87, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8359.13, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 32360.87, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Perc rf ablate renal tumor", "code_information": [ { "code": "50592", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4300.51, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3185.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 19122.29, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 34697.72, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4300.51, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 34697.72, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Percut ablate liver rf", "code_information": [ { "code": "47382", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4300.51, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3185.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 16163.4, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 29328.77, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4300.51, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 29328.77, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PERFLUTREN LIPID MICROSPHERE 6.52 MG/ML IV SUSP", "drug_information": { "unit": "1.500000", "type": "UN" }, "code_information": [ { "code": "11994001104", "type": "NDC" } ], "standard_charges": [ { "minimum": 123.46, "maximum": 411.82, "gross_charge": 438.11, "discounted_cash": 240.96, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 254.1, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 239.21, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 350.49, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 371.08, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 127.49, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 210.29, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 262.43, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 261.99, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 411.82, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 385.54, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 123.46, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 372.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 328.58, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 154.35, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 297.91, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 411.82, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 343.04, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 239.21, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 348.3, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 328.58, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 385.54, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 254.1, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 239.21, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PERFLUTREN PROTEIN A MICROSPH IV SUSP", "drug_information": { "unit": "3.000000", "type": "UN" }, "code_information": [ { "code": "00407270703", "type": "NDC" } ], "standard_charges": [ { "minimum": 138.48, "maximum": 461.92, "gross_charge": 491.4, "discounted_cash": 270.27, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 285.01, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 268.3, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 393.12, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 416.22, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 143.0, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 235.87, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 294.35, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 293.86, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 461.92, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 432.43, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 138.48, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 417.69, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 368.55, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 173.12, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 334.15, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 461.92, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 384.77, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 268.3, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 390.66, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 368.55, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 432.43, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 285.01, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 268.3, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Peri-implt capslc brst compl", "code_information": [ { "code": "19371", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2822.56, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2090.79, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 18206.43, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 33035.86, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2822.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 33035.86, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PERMETHRIN 1 % EX LIQD", "drug_information": { "unit": "59.000000", "type": "UN" }, "code_information": [ { "code": "63736002403", "type": "NDC" } ], "standard_charges": [ { "minimum": 5.69, "maximum": 18.97, "gross_charge": 20.18, "discounted_cash": 11.1, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.7, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.02, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.14, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.09, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.87, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.69, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.09, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.07, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.97, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.76, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.69, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.15, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.14, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.11, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.97, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.8, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.02, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.04, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.14, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.76, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.7, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.02, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PERMETHRIN 5 % EX CREA", "drug_information": { "unit": "60.000000", "type": "GR" }, "code_information": [ { "code": "21922002107", "type": "NDC" } ], "standard_charges": [ { "minimum": 9.31, "maximum": 31.07, "gross_charge": 33.05, "discounted_cash": 18.18, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.17, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.05, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.44, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.99, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.62, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.86, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.8, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.76, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.07, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.08, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.31, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.09, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.79, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.47, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.07, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.88, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.05, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.27, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.79, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.08, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.17, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.05, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PERPHENAZINE 2 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00904659961", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PERPHENAZINE 4 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00904660061", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PERPHENAZINE 8 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68084060701", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Perq abltj lvr cryoablation", "code_information": [ { "code": "47383", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 7674.11, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5684.53, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 21316.68, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 38679.47, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7674.11, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 38679.47, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Perq cervicothoracic inject", "code_information": [ { "code": "22510", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2391.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1771.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 33677.32, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 61108.04, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2391.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 61108.04, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Perq clsr tcat l atr apndge", "code_information": [ { "code": "33340", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 46394.27, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 84183.17, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 84183.17, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Perq dev breast 1st mr guide", "code_information": [ { "code": "19287", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 518.62, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 384.16, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 2390.72, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 4338.01, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 518.62, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 4338.01, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Perq dev breast 1st us imag", "code_information": [ { "code": "19285", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 518.62, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 384.16, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 8352.64, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 15156.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 518.62, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 15156.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Perq device breast 1st imag", "code_information": [ { "code": "19281", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1194.28, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 884.65, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 5069.12, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 9198.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1194.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 9198.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Perq lamot/lam crv/thrc", "code_information": [ { "code": "0274T", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 5265.64, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3900.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 25873.76, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 46948.36, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5265.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 46948.36, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Perq lamot/lam lumbar", "code_information": [ { "code": "0275T", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 5265.64, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3900.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 7509.44, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 13626.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5265.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 13626.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Perq lumb&thor vert aug", "code_information": [ { "code": "C7508", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 14108.43, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 25600.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 25600.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Perq lumbosacral injection", "code_information": [ { "code": "22511", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2391.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1771.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 40193.28, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 72949.39, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2391.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 72949.39, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Perq nl/pl lithotrp cplx>2cm", "code_information": [ { "code": "50081", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 6816.07, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5048.94, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 28487.52, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 51691.19, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6816.07, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 51691.19, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Perq nl/pl lithotrp smpl<2cm", "code_information": [ { "code": "50080", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 6816.07, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5048.94, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 23863.14, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 43300.09, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6816.07, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 43300.09, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Perq p-art revsc 1 abnor uni", "code_information": [ { "code": "33902", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 13235.9, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 9804.37, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 36851.29, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 66867.3, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 13235.9, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 66867.3, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Perq plmt bile duct stent", "code_information": [ { "code": "47538", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4300.51, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3185.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 16257.48, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 29499.46, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4300.51, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 29499.46, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Perq sacral augmt bilat inj", "code_information": [ { "code": "0201T", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 5265.64, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3900.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 16310.74, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 29596.12, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5265.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 29596.12, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Perq sacral augmt unilat inj", "code_information": [ { "code": "0200T", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 5265.64, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3900.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 12037.3, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 21841.87, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5265.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 21841.87, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Perq transcath closure pda", "code_information": [ { "code": "93582", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 13235.9, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 9804.37, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 24982.8, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 45331.71, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 13235.9, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 45331.71, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Perq transcath cls mitral", "code_information": [ { "code": "93590", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 13235.9, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 9804.37, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 44699.51, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 81108.02, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 13235.9, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 81108.02, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Perq trluml angp nt/recr coa", "code_information": [ { "code": "33897", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 26360.91, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 47832.3, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 47832.3, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Perq vertebral augmentation", "code_information": [ { "code": "22513", "type": "HCPCS" }, { "code": "22514", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 5265.64, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3900.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 30986.06, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 56224.73, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5265.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 56224.73, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PERTUZ-TRASTUZ-HYALURON-ZZXF 80-40-2000 MG-MG-U/ML SC SOLN", "drug_information": { "unit": "15.000000", "type": "UN" }, "code_information": [ { "code": "50242024501", "type": "NDC" } ], "standard_charges": [ { "minimum": 10695.49, "maximum": 35676.92, "gross_charge": 37954.17, "discounted_cash": 20874.79, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 22013.42, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 20722.98, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30363.34, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32147.18, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11044.66, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 18218.0, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 22734.55, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 11394.0, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35676.92, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33399.67, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 10695.49, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32261.04, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 28465.63, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 13371.25, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 25808.84, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 35676.92, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 29718.12, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 20722.98, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 15189.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 28465.63, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33399.67, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 22013.42, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 20722.98, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PERTUZUMAB 420 MG/14ML IV SOLN", "drug_information": { "unit": "14.000000", "type": "UN" }, "code_information": [ { "code": "50242014501", "type": "NDC" } ], "standard_charges": [ { "minimum": 8.8, "maximum": 18405.52, "gross_charge": 19580.34, "discounted_cash": 10769.19, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 11356.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.8, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15664.27, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16584.55, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5697.88, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9398.56, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 11728.62, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 11394.0, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 18405.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17230.7, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 5517.74, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16643.29, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14685.26, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 6898.15, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 13314.63, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 18405.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 15331.41, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.88, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 15189.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14685.26, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17230.7, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 11356.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.8, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "PET IDS 11-C BTA BENZTHIAZOLEAMYLOID", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "08252000196", "type": "NDC" } ], "standard_charges": [ { "minimum": 236.71, "maximum": 789.6, "gross_charge": 840.0, "discounted_cash": 462.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 487.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 458.64, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 672.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 711.48, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 244.44, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 403.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 503.16, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 502.32, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 789.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 739.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 236.71, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 714.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 630.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 295.93, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 571.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 789.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 657.72, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 458.64, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 667.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 630.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 739.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 487.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 458.64, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PET IDS 18-F CLOFARABINE", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "08252000207", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.28, "maximum": 0.94, "gross_charge": 1.0, "discounted_cash": 0.55, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.58, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.55, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.85, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.29, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.6, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.6, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.94, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.88, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.28, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.85, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.35, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.68, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.94, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.78, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.55, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.88, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.58, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.55, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PET IDS 18-F DCFPYL", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "08252000222", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.28, "maximum": 0.94, "gross_charge": 1.0, "discounted_cash": 0.55, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.58, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.55, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.85, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.29, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.6, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.6, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.94, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.88, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.28, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.85, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.35, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.68, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.94, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.78, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.55, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.88, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.58, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.55, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PET IDS 18-F DDNP", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "08252000197", "type": "NDC" } ], "standard_charges": [ { "minimum": 177.53, "maximum": 592.2, "gross_charge": 630.0, "discounted_cash": 346.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 365.4, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 343.98, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 504.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 533.61, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 183.33, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 302.4, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 377.37, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 376.74, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 592.2, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 554.4, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 177.53, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 535.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 472.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 221.95, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 428.4, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 592.2, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 493.29, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 343.98, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 500.85, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 472.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 554.4, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 365.4, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 343.98, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PET IDS 18-F FAPI-74", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00000999961", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.28, "maximum": 0.94, "gross_charge": 1.0, "discounted_cash": 0.55, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.58, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.55, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.85, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.29, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.6, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.6, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.94, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.88, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.28, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.85, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.35, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.68, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.94, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.78, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.55, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.88, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.58, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.55, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PET IDS 18-F FHBG", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "08252000129", "type": "NDC" } ], "standard_charges": [ { "minimum": 659.41, "maximum": 2199.6, "gross_charge": 2340.0, "discounted_cash": 1287.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1357.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1277.64, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1872.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1981.98, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 680.94, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1123.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1401.66, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 1399.32, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2199.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2059.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 659.41, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1989.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1755.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 824.38, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1591.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2199.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1832.22, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1277.64, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1860.3, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1755.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2059.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1357.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1277.64, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PET IDS 18-F FLORBETABEN (NEURACEQ)", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "08252000204", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.28, "maximum": 0.94, "gross_charge": 1.0, "discounted_cash": 0.55, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.58, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.55, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.85, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.29, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.6, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.6, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.94, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.88, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.28, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.85, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.35, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.68, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.94, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.78, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.55, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.88, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.58, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.55, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PET IDS 18-F FLORBETAPIR (AMYVID)", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "08252000209", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.28, "maximum": 0.94, "gross_charge": 1.0, "discounted_cash": 0.55, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.58, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.55, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.85, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.29, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.6, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.6, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.94, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.88, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.28, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.85, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.35, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.68, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.94, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.78, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.55, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.88, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.58, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.55, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PET IDS 18-F FLORTAUCIPIR (AV-1451)", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "08252000203", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.28, "maximum": 0.94, "gross_charge": 1.0, "discounted_cash": 0.55, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.58, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.55, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.85, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.29, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.6, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.6, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.94, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.88, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.28, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.85, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.35, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.68, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.94, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.78, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.55, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.88, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.58, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.55, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PET IDS 18-F FLT", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "04444000059", "type": "NDC" } ], "standard_charges": [ { "minimum": 659.41, "maximum": 2199.6, "gross_charge": 2340.0, "discounted_cash": 1287.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1357.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1277.64, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1872.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1981.98, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 680.94, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1123.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1401.66, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 1399.32, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2199.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2059.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 659.41, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1989.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1755.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 824.38, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1591.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2199.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1832.22, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1277.64, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1860.3, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1755.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2059.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1357.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1277.64, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PET IDS 18-F FLURPIRIDAZ", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "08252000198", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.28, "maximum": 0.94, "gross_charge": 1.0, "discounted_cash": 0.55, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.58, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.55, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.85, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.29, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.6, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.6, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.94, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.88, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.28, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.85, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.35, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.68, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.94, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.78, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.55, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.88, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.58, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.55, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PET IDS 18-F FLUTEMETAMOL (VIZAMYL)", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "08252000205", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.28, "maximum": 0.94, "gross_charge": 1.0, "discounted_cash": 0.55, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.58, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.55, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.85, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.29, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.6, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.6, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.94, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.88, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.28, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.85, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.35, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.68, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.94, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.78, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.55, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.88, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.58, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.55, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PET IDS 18-F HX4 HYPOXIA", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "08252000195", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.28, "maximum": 0.94, "gross_charge": 1.0, "discounted_cash": 0.55, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.58, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.55, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.85, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.29, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.6, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.6, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.94, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.88, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.28, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.85, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.35, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.68, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.94, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.78, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.55, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.88, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.58, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.55, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PET IDS 18-F LFAC", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "04444000058", "type": "NDC" } ], "standard_charges": [ { "minimum": 9412.12, "maximum": 31396.0, "gross_charge": 33400.0, "discounted_cash": 18370.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 19372.0, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 18236.4, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 26720.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 28289.8, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9719.4, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16032.0, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 20006.6, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 11394.0, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 31396.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 29392.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 9412.12, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 28390.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 25050.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11766.82, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 22712.0, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31396.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 26152.2, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 18236.4, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 15189.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 25050.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 29392.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 19372.0, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 18236.4, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PET IDS 18-F METHYL 4-FDG", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "08252000194", "type": "NDC" } ], "standard_charges": [ { "minimum": 140.9, "maximum": 470.0, "gross_charge": 500.0, "discounted_cash": 275.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 290.0, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 273.0, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 400.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 423.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 145.5, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 240.0, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 299.5, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 299.0, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 470.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 440.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 140.9, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 425.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 375.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 176.15, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 340.0, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 470.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 391.5, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 273.0, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 397.5, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 375.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 440.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 290.0, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 273.0, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PET IDS 18-F MK6240", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "08252000206", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.28, "maximum": 0.94, "gross_charge": 1.0, "discounted_cash": 0.55, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.58, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.55, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.85, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.29, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.6, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.6, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.94, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.88, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.28, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.85, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.35, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.68, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.94, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.78, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.55, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.88, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.58, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.55, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PET IDS 18-F MPPF", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "08252000199", "type": "NDC" } ], "standard_charges": [ { "minimum": 140.9, "maximum": 470.0, "gross_charge": 500.0, "discounted_cash": 275.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 290.0, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 273.0, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 400.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 423.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 145.5, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 240.0, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 299.5, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 299.0, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 470.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 440.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 140.9, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 425.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 375.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 176.15, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 340.0, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 470.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 391.5, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 273.0, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 397.5, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 375.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 440.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 290.0, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 273.0, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PET IDS GA-68 FAPI-46", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "08252000217", "type": "NDC" } ], "standard_charges": [ { "minimum": 285.31, "maximum": 951.69, "gross_charge": 1012.44, "discounted_cash": 556.84, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 587.22, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 552.79, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 809.95, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 857.54, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 294.62, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 485.97, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 606.45, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 605.44, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 951.69, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 890.95, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 285.31, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 860.57, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 759.33, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 356.68, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 688.46, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 951.69, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 792.74, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 552.79, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 804.89, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 759.33, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 890.95, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 587.22, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 552.79, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PET IDS GA-68 FAPI-46 SOFIE", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "08252000251", "type": "NDC" } ], "standard_charges": [ { "minimum": 507.24, "maximum": 1692.0, "gross_charge": 1800.0, "discounted_cash": 990.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1044.0, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 982.8, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1440.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1524.6, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 523.8, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 864.0, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1078.2, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 1076.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1692.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1584.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 507.24, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1530.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1350.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 634.14, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1224.0, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1692.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1409.4, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 982.8, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1431.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1350.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1584.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1044.0, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 982.8, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PET IDS GA-68 GOZETOTIDE", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "08252000095", "type": "NDC" } ], "standard_charges": [ { "minimum": 1011.02, "maximum": 3372.47, "gross_charge": 3587.73, "discounted_cash": 1973.25, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2080.88, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1958.9, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2870.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3038.81, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1044.03, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1722.11, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2149.05, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2145.46, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3372.47, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3157.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1011.02, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3049.57, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2690.8, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1263.96, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2439.66, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3372.47, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2809.19, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1958.9, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2852.25, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2690.8, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3157.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2080.88, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1958.9, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PET IDS ZR-89 GIRENTUXIMAB (TLX250)", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "08252000221", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.28, "maximum": 0.94, "gross_charge": 1.0, "discounted_cash": 0.55, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.58, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.55, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.85, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.29, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.6, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.6, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.94, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.88, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.28, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.85, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.35, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.68, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.94, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.78, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.55, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.88, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.58, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.55, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PET ISOTOPE 11-C ACETATE", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "04444000006", "type": "NDC" } ], "standard_charges": [ { "minimum": 470.61, "maximum": 1569.8, "gross_charge": 1670.0, "discounted_cash": 918.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 968.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 911.82, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1336.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1414.49, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 485.97, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 801.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1000.33, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 998.66, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1569.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1469.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 470.61, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1419.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1252.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 588.34, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1135.6, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1569.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1307.61, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 911.82, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1327.65, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1252.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1469.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 968.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 911.82, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PET ISOTOPE 15-O H2O (WATER)", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "04444000003", "type": "NDC" } ], "standard_charges": [ { "minimum": 236.71, "maximum": 789.6, "gross_charge": 840.0, "discounted_cash": 462.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 487.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 458.64, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 672.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 711.48, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 244.44, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 403.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 503.16, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 502.32, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 789.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 739.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 236.71, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 714.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 630.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 295.93, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 571.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 789.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 657.72, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 458.64, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 667.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 630.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 739.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 487.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 458.64, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PET ISOTOPE 18-F DOPA", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "04444000002", "type": "NDC" } ], "standard_charges": [ { "minimum": 941.21, "maximum": 3139.6, "gross_charge": 3340.0, "discounted_cash": 1837.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1937.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1823.64, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2672.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2828.98, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 971.94, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1603.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2000.66, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 1997.32, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3139.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2939.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 941.21, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2839.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2505.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1176.68, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2271.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3139.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2615.22, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1823.64, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2655.3, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2505.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2939.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1937.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1823.64, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PET ISOTOPE 18-F FDG", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "76394381201", "type": "NDC" } ], "standard_charges": [ { "minimum": 115.15, "maximum": 384.11, "gross_charge": 408.63, "discounted_cash": 224.75, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 237.01, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 223.11, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 326.9, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 346.11, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 118.91, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 196.14, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 244.77, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 244.36, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 384.11, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 359.59, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 115.15, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 347.34, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 306.47, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 143.96, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 277.87, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 384.11, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 319.96, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 223.11, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 324.86, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 306.47, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 359.59, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 237.01, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 223.11, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PHENAZOPYRIDINE HCL 100 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "R6516268110", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PHENAZOPYRIDINE HCL 200 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "1013562101", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PHENOBARBITAL 16.2 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "1351711001", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.25, "maximum": 7.52, "gross_charge": 8.0, "discounted_cash": 4.4, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.4, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.78, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.33, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.84, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.79, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.25, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.8, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.82, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.44, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.26, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.36, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PHENOBARBITAL 20 MG/5ML PO ELIX", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "1351710716", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.25, "maximum": 7.52, "gross_charge": 8.0, "discounted_cash": 4.4, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.4, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.78, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.33, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.84, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.79, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.25, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.8, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.82, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.44, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.26, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.36, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PHENOBARBITAL 20 MG/5ML PO ELIX (NICU)", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "0121053105", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.25, "maximum": 7.52, "gross_charge": 8.0, "discounted_cash": 4.4, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.4, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.78, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.33, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.84, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.79, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.25, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.8, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.82, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.44, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.26, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.36, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PHENOBARBITAL 32.4 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00904657561", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.25, "maximum": 7.52, "gross_charge": 8.0, "discounted_cash": 4.4, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.4, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.78, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.33, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.84, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.79, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.25, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.8, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.82, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.44, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.26, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.36, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PHENOBARBITAL 64.8 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "R1657166701", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.25, "maximum": 7.52, "gross_charge": 8.0, "discounted_cash": 4.4, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.4, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.78, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.33, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.84, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.79, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.25, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.8, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.82, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.44, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.26, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.36, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PHENOBARBITAL 90 MG SUPPOSITORY", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "P8252000078", "type": "NDC" } ], "standard_charges": [ { "minimum": 19.41, "maximum": 64.76, "gross_charge": 68.89, "discounted_cash": 37.89, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.96, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.61, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.11, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 58.35, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.05, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.07, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.27, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.2, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 64.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.62, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.41, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 58.56, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 51.67, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.27, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.85, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 64.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 53.94, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.61, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.77, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 51.67, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.62, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.96, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.61, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PHENOBARBITAL 97.2 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "1351711301", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.25, "maximum": 7.52, "gross_charge": 8.0, "discounted_cash": 4.4, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.4, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.78, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.33, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.84, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.79, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.25, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.8, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.82, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.44, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.26, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.36, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PHENOBARBITAL SODIUM 100 MG IV SOLR", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "62756030101", "type": "NDC" } ], "standard_charges": [ { "minimum": 109.79, "maximum": 366.24, "gross_charge": 389.62, "discounted_cash": 214.29, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 225.98, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 212.73, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 311.7, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 330.01, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 113.38, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 187.02, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 233.38, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 232.99, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 366.24, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 342.87, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 109.79, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 331.18, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 292.22, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 137.26, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 264.94, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 366.24, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 305.07, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 212.73, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 309.75, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 292.22, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 342.87, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 225.98, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 212.73, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PHENOBARBITAL SODIUM 130 MG/ML IJ SOLN", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "14789012805", "type": "NDC" } ], "standard_charges": [ { "minimum": 17.13, "maximum": 57.15, "gross_charge": 60.8, "discounted_cash": 33.44, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.26, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.2, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 48.64, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 51.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.69, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.18, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.42, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.36, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 57.15, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 53.5, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 51.68, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.6, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.42, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.34, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 57.15, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.61, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.2, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 48.34, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.6, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 53.5, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.26, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.2, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PHENOBARBITAL SODIUM 65 MG/ML IJ SOLN", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "14789012705", "type": "NDC" } ], "standard_charges": [ { "minimum": 12.68, "maximum": 42.3, "gross_charge": 45.0, "discounted_cash": 24.75, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.1, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.12, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.1, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.91, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.3, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.68, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.25, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.85, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.6, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.3, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.24, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.78, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.1, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PHENOL 1.4 % MT LIQD", "drug_information": { "unit": "177.000000", "type": "UN" }, "code_information": [ { "code": "00536122858", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.8, "maximum": 6.02, "gross_charge": 6.4, "discounted_cash": 3.52, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.71, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.49, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.12, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.42, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.86, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.07, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.83, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.83, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.02, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.63, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.8, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.44, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.8, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.25, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.35, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.02, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.01, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.49, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.09, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.8, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.63, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.71, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.49, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PHENOL 80 % LIQD", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "08252193810", "type": "NDC" } ], "standard_charges": [ { "minimum": 17.95, "maximum": 1158.0, "gross_charge": 63.68, "discounted_cash": 35.02, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.93, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.77, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.27, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.53, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.57, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.14, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.08, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.86, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 56.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.95, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.13, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.76, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.43, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.3, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.86, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.86, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.77, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.63, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.76, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 56.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.93, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.77, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PHENOXYBENZAMINE 2 MG/ML ORAL SUSPENSION", "drug_information": { "unit": "50.000000", "type": "UN" }, "code_information": [ { "code": "P8252000090", "type": "NDC" } ], "standard_charges": [ { "minimum": 1579.67, "maximum": 5269.29, "gross_charge": 5605.63, "discounted_cash": 3083.1, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3251.27, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3060.67, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4484.5, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4747.97, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1631.24, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2690.7, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3357.77, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 3352.17, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5269.29, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4932.95, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1579.67, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4764.79, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4204.22, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1974.86, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3811.83, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5269.29, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4389.21, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3060.67, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4456.48, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4204.22, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4932.95, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3251.27, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3060.67, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PHENOXYBENZAMINE HCL 10 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60219150201", "type": "NDC" } ], "standard_charges": [ { "minimum": 17.55, "maximum": 58.53, "gross_charge": 62.27, "discounted_cash": 34.25, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.12, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.82, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.74, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.12, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.89, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.3, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.24, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 58.53, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.55, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.93, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.7, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.94, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.34, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 58.53, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 48.76, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.5, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.7, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.12, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PHENTOLAMINE MESYLATE 5 MG IJ SOLR", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68094010120", "type": "NDC" } ], "standard_charges": [ { "minimum": 200.45, "maximum": 1086.34, "gross_charge": 1155.68, "discounted_cash": 635.62, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 670.29, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 200.45, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 924.54, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 978.86, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 336.3, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 554.73, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 692.25, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 691.1, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1086.34, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1017.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 325.67, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 982.33, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 866.76, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 407.15, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 785.86, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1086.34, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 904.9, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 270.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 918.77, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 866.76, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1017.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 670.29, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 200.45, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "PHENYLEPHRINE 100 MCG/ML IN NACL 0.9% 10 ML 503B SYRINGE (PRIAPISM)", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "73177010803", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PHENYLEPHRINE HCL (PRESSORS) 10 MG/ML IV SOLN", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "23155062041", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PHENYLEPHRINE HCL 0.25 % NA SOLN", "drug_information": { "unit": "15.000000", "type": "UN" }, "code_information": [ { "code": "00225080047", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.22, "maximum": 7.41, "gross_charge": 7.88, "discounted_cash": 4.33, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.57, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.3, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.3, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.67, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.29, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.78, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.72, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.71, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.41, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.93, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.22, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.7, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.91, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.78, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.36, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.41, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.17, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.3, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.26, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.91, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.93, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.57, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.3, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PHENYLEPHRINE HCL 0.25 % NA SOLN 15 ML BOTTLE (BULK CHARGE)", "drug_information": { "unit": "15.000000", "type": "UN" }, "code_information": [ { "code": "00225080047_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.22, "maximum": 7.41, "gross_charge": 7.88, "discounted_cash": 4.33, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.57, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.3, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.3, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.67, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.29, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.78, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.72, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.71, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.41, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.93, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.22, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.7, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.91, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.78, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.36, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.41, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.17, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.3, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.26, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", 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"standard_charges": [ { "minimum": 2.22, "maximum": 7.41, "gross_charge": 7.88, "discounted_cash": 4.33, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.57, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.3, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.3, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.67, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.29, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.78, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.72, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.71, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.41, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.93, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.22, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.7, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.91, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.78, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.36, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.41, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.17, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.3, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.26, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.91, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.93, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.57, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.3, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PHENYLEPHRINE HCL 1 % NA SOLN", "drug_information": { "unit": "15.000000", "type": "UN" }, "code_information": [ { "code": "00225081047", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.49, "maximum": 8.3, "gross_charge": 8.83, "discounted_cash": 4.86, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.12, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.82, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.06, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.48, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.57, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.24, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.29, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.28, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.3, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.77, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.49, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.51, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.62, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.11, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.3, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.91, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.82, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.02, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.62, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.77, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.12, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.82, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PHENYLEPHRINE HCL 1 MG/10ML IV SOLN/SOSY (MULTI-GPI)", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "73177010803_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PHENYLEPHRINE HCL 10 % OP SOLN", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "70756061430", "type": "NDC" } ], "standard_charges": [ { "minimum": 20.59, "maximum": 68.67, "gross_charge": 73.05, "discounted_cash": 40.18, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.37, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.89, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 58.44, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.87, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.26, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.06, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.76, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.68, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 68.67, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 64.28, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.59, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 62.09, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.79, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.74, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.67, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 68.67, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 57.2, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.89, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 58.07, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.79, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 64.28, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.37, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.89, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PHENYLEPHRINE HCL 100 MCG/ML (PF) IN 0.9% SODIUM CHLORIDE 10ML", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "73177010803_3", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PHENYLEPHRINE HCL 100 MCG/ML (PF) IN 0.9% SODIUM CHLORIDE 10ML (ANES/PULM CRIT/ED)", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "73177010803_4", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PHENYLEPHRINE HCL 2.5 % OP SOLN", "drug_information": { "unit": "2.000000", "type": "UN" }, "code_information": [ { "code": "70756062925", "type": "NDC" } ], "standard_charges": [ { "minimum": 16.89, "maximum": 56.33, "gross_charge": 59.93, "discounted_cash": 32.96, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.76, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.72, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.94, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.76, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.44, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.77, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.9, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.84, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 56.33, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.74, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.89, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.94, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 44.95, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.11, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.75, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 56.33, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.93, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.72, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.64, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 44.95, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.74, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.76, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.72, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PHENYLEPHRINE HCL 50 MG/250 ML DRIP RTU (CENTRAL)(TITRATABLE/ICU)", "drug_information": { "unit": "250.000000", "type": "UN" }, "code_information": [ { "code": "71266525001", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", 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60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PHENYLEPHRINE HCL 50 MG/250 ML DRIP RTU (TITRATABLE/ICU)(PERIPHERAL)", "drug_information": { "unit": "250.000000", "type": "UN" }, "code_information": [ { "code": "70092904505", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", 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}, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", 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"inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1095.04, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.74, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1510.4, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1599.14, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 549.41, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 906.24, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1130.91, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 1129.02, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1774.72, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1661.44, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 532.04, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1604.8, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1416.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 665.14, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1283.84, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1774.72, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1478.3, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 71.2, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1500.96, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1416.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1661.44, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1095.04, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.74, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "PHENYLEPHRINE-MINERAL OIL-PET 0.25-14-74.9 % RE OINT", "drug_information": { "unit": "57.000000", "type": "GR" }, "code_information": [ { "code": "00536128806", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.34, "maximum": 4.47, "gross_charge": 4.75, "discounted_cash": 2.61, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.76, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.59, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.02, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.38, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.28, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.85, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.84, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.47, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.18, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.34, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.04, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.56, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.67, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.23, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.47, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.72, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.59, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.78, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.56, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.18, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.76, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.59, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PHENYTOIN 125 MG/5ML PO SUSP", "drug_information": { "unit": "4.000000", "type": "UN" }, "code_information": [ { "code": "60687027566", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.64, "maximum": 8.8, "gross_charge": 9.36, "discounted_cash": 5.15, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.43, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.11, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.49, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.93, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.49, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.61, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.6, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.24, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.64, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.96, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.02, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.3, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.36, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.33, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.11, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.44, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.02, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.24, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.43, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.11, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PHENYTOIN 50 MG PO CHEW", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687015625", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PHENYTOIN SODIUM 50 MG/ML IJ SOLN", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "00641255510", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PHENYTOIN SODIUM EXTENDED 100 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00071036940", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.19, "maximum": 3.96, "gross_charge": 4.21, "discounted_cash": 2.32, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.44, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.3, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.37, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.57, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.23, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.02, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.52, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.52, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.96, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.7, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.19, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.58, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.16, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.48, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.86, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.96, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.3, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.3, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.35, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.16, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.7, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.44, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.3, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Phleb veins - extrem 20+", "code_information": [ { "code": "37766", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2320.02, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1718.54, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 7630.96, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 14116.5, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2320.02, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 14116.5, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PHOSPHORUS P-32 INJECTION", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "51808012701", "type": "NDC" } ], "standard_charges": [ { "minimum": 377.33, "maximum": 1258.65, "gross_charge": 1338.99, "discounted_cash": 736.44, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 776.61, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 731.09, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1071.19, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1134.12, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 389.65, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 642.72, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 802.06, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 800.72, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1258.65, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1178.31, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 377.33, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1138.14, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1004.24, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 471.73, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 910.51, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1258.65, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1048.43, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 731.09, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1064.5, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1004.24, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1178.31, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 776.61, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 731.09, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Photopheresis", "code_information": [ { "code": "36522", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 3453.44, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 9515.26, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 17265.6, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3453.44, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 17265.6, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PHOXILLUM BK4/2.5 32-4-2.5-1 MEQ-MMOL/L EC SOLN", "drug_information": { "unit": "5000.000000", "type": "UN" }, "code_information": [ { "code": "24571011606", "type": "NDC" } ], "standard_charges": [ { "minimum": 28.18, "maximum": 1158.0, "gross_charge": 100.0, "discounted_cash": 55.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 58.0, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.6, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.8, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.1, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 48.0, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.9, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.8, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 94.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.18, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 85.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.23, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 68.0, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 94.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 78.3, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.6, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 79.5, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 58.0, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.6, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PHYSOSTIGMINE SALICYLATE 0.4 MG/ML IJ SOLN", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "81284083105", "type": "NDC" } ], "standard_charges": [ { "minimum": 123.29, "maximum": 1158.0, "gross_charge": 437.5, "discounted_cash": 240.63, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 253.75, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 238.88, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 379.75, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 127.31, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 210.0, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 262.06, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 261.63, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 411.25, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 385.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 123.29, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 371.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 328.13, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 154.13, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 297.5, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 411.25, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 342.56, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 238.88, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 347.81, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 328.13, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 385.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 253.75, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 238.88, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PHYTONADIONE 1 MG/0.5 ML IM SYRINGE (NICU)", "drug_information": { "unit": "0.500000", "type": "UN" }, "code_information": [ { "code": "00409915701", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", 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"methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", 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"description": "PHYTONADIONE 1 MG/0.5ML IJ SOLN", "drug_information": { "unit": "0.500000", "type": "UN" }, "code_information": [ { "code": "69097070996", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { 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}, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, 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34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": 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charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PHYTONADIONE 5 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687038194", "type": "NDC" } ], "standard_charges": [ { "minimum": 29.56, "maximum": 98.62, "gross_charge": 104.91, "discounted_cash": 57.7, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.85, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 57.28, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 83.93, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.86, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.53, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.36, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 62.84, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 62.74, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 98.62, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 92.32, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.56, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 89.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 78.68, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.96, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 71.34, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 98.62, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.14, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 57.28, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 83.4, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 78.68, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 92.32, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.85, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 57.28, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Pierce skull implant device", "code_information": [ { "code": "61210", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 22955.84, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 41674.64, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 41674.64, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PIFLUFOLASTAT F 18 9 MCI IV SOSY", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "71258002200", "type": "NDC" } ], "standard_charges": [ { "minimum": 181.51, "maximum": 13361.16, "gross_charge": 14214.0, "discounted_cash": 7817.7, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 8244.12, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 181.51, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11371.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12039.26, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { 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"percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12508.32, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 4005.51, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12081.9, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10660.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 5007.59, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 9665.52, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 13361.16, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 11129.56, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 245.04, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 11300.13, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10660.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12508.32, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8244.12, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 181.51, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "PILOCARPINE HCL 1 % OP SOLN", "drug_information": { "unit": "15.000000", "type": "UN" }, "code_information": [ { "code": "61314020315", "type": "NDC" } ], "standard_charges": [ { "minimum": 51.89, "maximum": 173.09, "gross_charge": 184.14, "discounted_cash": 101.28, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 106.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 100.54, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 147.31, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 155.97, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 53.58, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.39, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 110.3, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 110.12, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 173.09, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 162.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 51.89, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 156.52, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 138.11, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 64.87, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 125.22, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 173.09, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 144.18, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 100.54, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 146.39, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 138.11, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 162.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 106.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 100.54, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PILOCARPINE HCL 2 % OP SOLN", "drug_information": { "unit": "15.000000", "type": "UN" }, "code_information": [ { "code": "70069019101", "type": "NDC" } ], "standard_charges": [ { "minimum": 19.34, "maximum": 64.51, "gross_charge": 68.63, "discounted_cash": 37.75, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.81, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.47, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.9, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 58.13, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.97, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.94, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.11, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.04, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 64.51, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.39, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.34, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 58.34, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 51.47, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.18, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.67, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 64.51, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 53.74, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.47, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.56, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 51.47, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.39, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.81, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.47, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PILOCARPINE HCL 5 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00527131301", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PIMECROLIMUS 1 % EX CREA", "drug_information": { "unit": "30.000000", "type": "GR" }, "code_information": [ { "code": "68682011001", "type": "NDC" } ], "standard_charges": [ { "minimum": 91.59, "maximum": 305.53, "gross_charge": 325.03, "discounted_cash": 178.77, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 188.52, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 177.47, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 260.02, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 275.3, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 94.58, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 156.01, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 194.69, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 194.37, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 305.53, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 286.03, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 91.59, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 276.28, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 243.77, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 114.51, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 221.02, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 305.53, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 254.5, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 177.47, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 258.4, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 243.77, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 286.03, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 188.52, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 177.47, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Pin finger dislocation", "code_information": [ { "code": "26776", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2391.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1771.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 5974.29, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 10840.46, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2391.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 10840.46, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Pin finger fracture each", "code_information": [ { "code": "26756", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2391.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1771.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 5924.92, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 10750.82, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2391.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 10750.82, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Pin hand dislocation", "code_information": [ { "code": "26676", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2391.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1771.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 9161.01, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 16622.8, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2391.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 16622.8, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Pin radioulnar dislocation", "code_information": [ { "code": "25671", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2391.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1771.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 20541.36, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 37272.66, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2391.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 37272.66, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Pin ulnar styloid fracture", "code_information": [ { "code": "25651", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2391.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1771.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 13835.83, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 25105.33, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2391.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 25105.33, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PINDOLOL 5 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00378005201", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PIOGLITAZONE HCL 15 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687039101", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PIOGLITAZONE HCL 30 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00093727256", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PIPERACILLIN SOD-TAZOBACTAM SO 2.25 (2-0.25) G IV SOLR", "drug_information": { "unit": "11.110000", "type": "UN" }, "code_information": [ { "code": "60505615604", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PIPERACILLIN SOD-TAZOBACTAM SO 3.375 (3-0.375) G IV SOLR", "drug_information": { "unit": "16.670000", "type": "UN" }, "code_information": [ { "code": "00781311395", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PIPERACILLIN SOD-TAZOBACTAM SO 4.5 (4-0.5) G IV SOLR", "drug_information": { "unit": "22.220000", "type": "UN" }, "code_information": [ { "code": "00781311495", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PIPERACILLIN-TAZOBACTAM 180 MG/ML OF PIPERACILLIN SYR (NICU)", "drug_information": { "unit": "11.110000", "type": "UN" }, "code_information": [ { "code": "64679003401", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PIPERACILLIN-TAZOBACTAM 180 MG/ML OF PIPERACILLIN SYR (PEDS)", "drug_information": { "unit": "11.110000", "type": "UN" }, "code_information": [ { "code": "64679003401_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PIPERACILLIN-TAZOBACTAM 3.375 G/50 ML RTU", "drug_information": { "unit": "50.000000", "type": "UN" }, "code_information": [ { "code": "00338963624", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PIPERACILLIN-TAZOBACTAM 3.375 GM/50 ML RTU (EXT 4HR)", "drug_information": { "unit": "50.000000", "type": "UN" }, "code_information": [ { "code": "00338963624_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PIPERACILLIN-TAZOBACTAM 4.5 GM/100 ML RTU", "drug_information": { "unit": "100.000000", "type": "UN" }, "code_information": [ { "code": "00338963812", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PIPERACILLIN-TAZOBACTAM 4.5 GM/100 ML RTU (EXT 4HR)", "drug_information": { "unit": "100.000000", "type": "UN" }, "code_information": [ { "code": "00338963812_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PIPERACILLIN-TAZOBACTAM SYRINGE PEDS (EXT 4HR)", "drug_information": { "unit": "11.110000", "type": "UN" }, "code_information": [ { "code": "64679003401_3", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PIPERACILLIN-TAZOBACTAM SYRINGE PEDS EXT ONCE", "drug_information": { "unit": "11.110000", "type": "UN" }, "code_information": [ { "code": "64679003401_4", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PIROXICAM 20 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00093075701", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.34, "maximum": 4.48, "gross_charge": 4.77, "discounted_cash": 2.62, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.77, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.6, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.82, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.04, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.39, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.29, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.86, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.85, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.48, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.34, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.05, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.58, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.68, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.24, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.48, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.73, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.6, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.79, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.58, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.77, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.6, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Place breast rad tube/caths", "code_information": [ { "code": "19298", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4806.97, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3560.72, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 27490.79, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 49886.1, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4806.97, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 49886.1, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Place cath carotd art", "code_information": [ { "code": "36224", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 3984.54, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2951.51, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 27371.23, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 49665.57, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3984.54, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 49665.57, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Place cath carotid/inom art", "code_information": [ { "code": "36222", "type": "HCPCS" }, { "code": "36223", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 3984.54, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1718.54, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2951.51, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 29756.72, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 53994.07, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2320.02, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3984.54, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 53994.07, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Place cath subclavian art", "code_information": [ { "code": "36225", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2320.02, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1718.54, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 26415.89, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 47932.09, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2320.02, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 47932.09, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Place cath vertebral art", "code_information": [ { "code": "36226", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 3984.54, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2951.51, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 27024.13, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 49035.75, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3984.54, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 49035.75, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Place catheter in aorta", "code_information": [ { "code": "36200", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 32828.44, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 59567.73, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 59567.73, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Place catheter in artery", "code_information": [ { "code": "36013", "type": "HCPCS" }, { "code": "36014", "type": "HCPCS" }, { "code": "36015", "type": "HCPCS" }, { "code": "36215", "type": "HCPCS" }, { "code": "36216", "type": "HCPCS" }, { "code": "36217", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 23718.76, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 43038.1, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 43038.1, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Place catheter in vein", "code_information": [ { "code": "36010", "type": "HCPCS" }, { "code": "36011", "type": "HCPCS" }, { "code": "36012", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 29019.8, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 52656.92, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 52656.92, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Place device/marker, non pro", "code_information": [ { "code": "C9728", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1008.54, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 747.07, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 8843.68, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 16047.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1008.54, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 16047.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Place endorectal app", "code_information": [ { "code": "C9725", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 672.02, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 497.79, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 38020.88, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 68989.5, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 672.02, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 68989.5, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Place gastrostomy tube perc", "code_information": [ { "code": "49440", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1398.27, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1035.76, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 16159.86, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 29322.33, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1398.27, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 29322.33, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Place needle in vein", "code_information": [ { "code": "36000", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 3387.32, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 6146.35, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 6146.35, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Place needles h&n for rt", "code_information": [ { "code": "41019", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4360.43, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3229.95, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 16371.41, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 29706.19, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4360.43, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 29706.19, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Place needles pelvic for rt", "code_information": [ { "code": "55920", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 3638.66, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2695.3, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 26693.13, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 48435.14, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3638.66, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 48435.14, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Place rt device/marker pros", "code_information": [ { "code": "55876", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1008.54, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 747.07, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 29963.15, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 54368.62, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1008.54, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 54368.62, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Placement of seton", "code_information": [ { "code": "46020", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2021.42, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1497.34, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 6200.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 11250.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2021.42, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 11250.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PLASMA-LYTE A IV BOLUS", "drug_information": { "unit": "1000.000000", "type": "UN" }, "code_information": [ { "code": "00338022104", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 1158.0, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.72, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PLASMA-LYTE-A PH 7.4 IV SOLN", "drug_information": { "unit": "1000.000000", "type": "UN" }, "code_information": [ { "code": "00338022104_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 19.73, "maximum": 1158.0, "gross_charge": 70.0, "discounted_cash": 38.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.76, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.37, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.93, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.86, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.73, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.66, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.6, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.81, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.65, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PLEGISOL PF SOLN", "drug_information": { "unit": "1000.000000", "type": "UN" }, "code_information": [ { "code": "00409796905", "type": "NDC" } ], "standard_charges": [ { "minimum": 28.18, "maximum": 1158.0, "gross_charge": 100.0, "discounted_cash": 55.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 58.0, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.6, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.8, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.1, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 48.0, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.9, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.8, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 94.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.18, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 85.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.23, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 68.0, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 94.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 78.3, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.6, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 79.5, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 58.0, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.6, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PLENAMINE 15 % IV SOLN", "drug_information": { "unit": "2000.000000", "type": "UN" }, "code_information": [ { "code": "00264450005", "type": "NDC" } ], "standard_charges": [ { "minimum": 49.69, "maximum": 1158.0, "gross_charge": 176.32, "discounted_cash": 96.98, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 102.27, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.27, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 153.05, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 51.31, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 84.63, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 105.62, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 105.44, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 165.74, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 155.16, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.69, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 149.87, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 132.24, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 62.12, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 119.9, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 165.74, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 138.06, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.27, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 140.17, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 132.24, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 155.16, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 102.27, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.27, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PLERIXAFOR 24 MG/1.2ML SC SOLN", "drug_information": { "unit": "1.200000", "type": "UN" }, "code_information": [ { "code": "71288015501", "type": "NDC" } ], "standard_charges": [ { "minimum": 27.56, "maximum": 804.54, "gross_charge": 855.89, "discounted_cash": 470.74, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 496.42, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 684.71, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 724.94, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 249.06, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 410.83, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 512.68, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 511.82, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 804.54, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 753.18, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 241.19, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 727.51, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 641.92, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 301.53, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 582.01, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 804.54, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 670.16, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.2, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 680.43, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 641.92, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 753.18, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 496.42, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "Plmt access bil tree sm bwl", "code_information": [ { "code": "47541", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4599.32, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3406.9, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 15523.96, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 29322.86, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4599.32, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 29322.86, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Plmt biliary drainage cath", "code_information": [ { "code": "47533", "type": "HCPCS" }, { "code": "47534", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2601.27, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1926.87, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 12739.01, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 23126.54, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2601.27, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 23126.54, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Plmt nephrostomy catheter", "code_information": [ { "code": "50432", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1509.96, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1118.49, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 10041.96, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 18221.29, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1509.96, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 18221.29, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Plmt nephroureteral catheter", "code_information": [ { "code": "50433", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2542.24, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1883.14, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 27722.12, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 50302.25, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2542.24, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 50302.25, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Plmt sft tiss loclzj dev 1st", "code_information": [ { "code": "10035", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 518.62, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 384.16, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 4439.2, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 8055.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 518.62, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 8055.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Plmt ureteral stent prq", "code_information": [ { "code": "50693", "type": "HCPCS" }, { "code": "50694", "type": "HCPCS" }, { "code": "50695", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2542.24, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1883.14, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 31454.77, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 57075.25, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2542.24, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 57075.25, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PNEUMOCOCCAL 20-VAL CONJ VACC 0.5 ML IM SUSY", "drug_information": { "unit": "0.500000", "type": "UN" }, "code_information": [ { "code": "00005200010", "type": "NDC" } ], "standard_charges": [ { "minimum": 205.76, "maximum": 686.36, "gross_charge": 730.17, "discounted_cash": 401.59, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 423.5, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 398.67, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 584.14, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 618.45, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 212.48, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 350.48, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 437.37, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 436.64, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 686.36, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 642.55, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 205.76, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 620.64, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 547.63, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 257.24, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 496.52, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 686.36, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 571.72, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 398.67, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 580.49, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 547.63, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 642.55, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 423.5, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 398.67, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PNEUMOCOCCAL VAC POLYVALENT 25 MCG/0.5ML IJ INJ (MULTI-GPI)", "drug_information": { "unit": "0.500000", "type": "UN" }, "code_information": [ { "code": "00006483703", "type": "NDC" } ], "standard_charges": [ { "minimum": 104.58, "maximum": 348.86, "gross_charge": 371.13, "discounted_cash": 204.12, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 215.26, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 202.64, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 296.9, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 314.35, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 108.0, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 178.14, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 222.31, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 221.94, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 348.86, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 326.59, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 104.58, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 315.46, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 278.35, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 130.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 252.37, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 348.86, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 290.59, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 202.64, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 295.05, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 278.35, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 326.59, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 215.26, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 202.64, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PODOPHYLLUM RESIN 25 % EX SOLN", "drug_information": { "unit": "15.000000", "type": "UN" }, "code_information": [ { "code": "00574060115", "type": "NDC" } ], "standard_charges": [ { "minimum": 53.75, "maximum": 179.29, "gross_charge": 190.73, "discounted_cash": 104.9, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 110.62, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 104.14, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 152.58, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 161.55, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.5, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 91.55, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 114.25, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 114.06, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 179.29, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 167.84, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 53.75, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 162.12, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 143.05, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 67.19, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 129.7, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 179.29, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 149.34, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 104.14, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 151.63, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 143.05, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 167.84, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 110.62, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 104.14, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "POLATUZUMAB VEDOTIN-PIIQ 140 MG IV SOLR", "drug_information": { "unit": "7.000000", "type": "UN" }, "code_information": [ { "code": "50242010501", "type": "NDC" } ], "standard_charges": [ { "minimum": 11394.0, "maximum": 42300.0, "gross_charge": 45000.0, "discounted_cash": 24750.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 26100.0, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 24570.0, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 36000.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38115.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13095.0, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21600.0, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 26955.0, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 11394.0, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42300.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39600.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 12681.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38250.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33750.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 15853.5, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 30600.0, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 42300.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 35235.0, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24570.0, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 15189.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33750.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39600.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 26100.0, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24570.0, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "POLATUZUMAB VEDOTIN-PIIQ 30 MG IV SOLR", "drug_information": { "unit": "1.500000", "type": "UN" }, "code_information": [ { "code": "50242010301", "type": "NDC" } ], "standard_charges": [ { "minimum": 70.86, "maximum": 10919.07, "gross_charge": 11616.03, "discounted_cash": 6388.82, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 6737.3, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 70.86, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9292.82, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9838.78, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3380.26, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5575.69, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6958.0, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 6946.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10919.07, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10222.11, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3273.4, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9873.63, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8712.02, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 4092.33, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7898.9, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 10919.07, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 9095.35, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 95.66, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 9234.74, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8712.02, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10222.11, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6737.3, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 70.86, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "POLIOVIRUS VACCINE INACTIVATED IJ INJ", "drug_information": { "unit": "0.500000", "type": "UN" }, "code_information": [ { "code": "49281086010", "type": "NDC" } ], "standard_charges": [ { "minimum": 25.89, "maximum": 86.35, "gross_charge": 91.86, "discounted_cash": 50.52, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 53.28, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.16, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 73.49, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 77.81, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.73, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 44.09, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.02, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.93, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.35, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 80.84, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.89, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 78.08, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 68.9, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.36, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 62.46, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.35, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 71.93, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.16, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 73.03, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 68.9, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 80.84, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 53.28, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.16, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "POLY-VI-SOL PO SOLN", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "1785604021", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "POLY-VI-SOL/IRON 11 MG/ML PO SOLN", "drug_information": { "unit": "0.500000", "type": "UN" }, "code_information": [ { "code": "00087040501", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "POLYETHYL GLYCOL-PROPYL GLYCOL 0.4-0.3 % OP GEL", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "00065045407", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "POLYETHYLENE GLYCOL 3350 17 G PO PACK", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687043192", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, 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"N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "POLYETHYLENE GLYCOL 3350 PO PACK (EP'D DOSES)", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687043192_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs 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charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", 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}, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "POLYMYXIN B-TRIMETHOPRIM 10000-0.1 UNIT/ML-% OP SOLN", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "61314062810", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "POLYSACCHARIDE IRON COMPLEX 150 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "51991020311", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "POLYSPORIN OINT PACKET (BULK CHARGE)", "drug_information": { "unit": "1.000000", "type": "GR" }, "code_information": [ { "code": "69968006009", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "POLYVINYL ALCOHOL 1.4 % OP SOLN", "drug_information": { "unit": "15.000000", "type": "UN" }, "code_information": [ { "code": "50268067815", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "POLYVINYL ALCOHOL-POVIDONE PF 1.4-0.6 % OP SOLN", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "C0023050601", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PORACTANT ALFA 120 MG/1.5ML INTRATRACHEA SUSP", "drug_information": { "unit": "1.500000", "type": "UN" }, "code_information": [ { "code": "10122051001", "type": "NDC" } ], "standard_charges": [ { "minimum": 581.76, "maximum": 1940.57, "gross_charge": 2064.44, "discounted_cash": 1135.44, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1197.38, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1127.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1791.93, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 600.75, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 990.93, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1236.6, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 1234.54, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1940.57, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1816.71, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 581.76, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1754.77, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1548.33, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 727.3, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1403.82, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1940.57, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1616.46, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1127.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1641.23, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1548.33, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1816.71, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1197.38, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1127.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PORACTANT ALFA 240 MG/3ML INTRATRACHEA SUSP", "drug_information": { "unit": "3.000000", "type": "UN" }, "code_information": [ { "code": "10122051003", "type": "NDC" } ], "standard_charges": [ { "minimum": 1132.2, "maximum": 3776.69, "gross_charge": 4017.76, "discounted_cash": 2209.77, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2330.3, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2193.7, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3487.42, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1169.17, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1928.52, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2406.64, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2402.62, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3776.69, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3535.63, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1132.2, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3415.1, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3013.32, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1415.46, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2732.08, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3776.69, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3145.91, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2193.7, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3194.12, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3013.32, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3535.63, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2330.3, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2193.7, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PORACTANT ALFA 80 MG/ML INTRATRACHEAL SUSP (MULTI GPI)", "drug_information": { "unit": "1.500000", "type": "UN" }, "code_information": [ { "code": "10122051001_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 581.76, "maximum": 1940.57, "gross_charge": 2064.44, "discounted_cash": 1135.44, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1197.38, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1127.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1791.93, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 600.75, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 990.93, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1236.6, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 1234.54, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1940.57, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1816.71, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 581.76, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1754.77, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1548.33, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 727.3, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1403.82, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1940.57, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1616.46, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1127.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1641.23, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1548.33, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1816.71, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1197.38, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1127.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "POSACONAZOLE 100 MG PO TBEC", "drug_information": { "unit": "3.000000", "type": "UN" }, "code_information": [ { "code": "60687052394", "type": "NDC" } ], "standard_charges": [ { "minimum": 34.14, "maximum": 113.89, "gross_charge": 121.16, "discounted_cash": 66.64, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 70.27, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 66.15, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.93, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 102.62, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.26, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 58.16, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 72.57, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 72.45, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 113.89, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 106.62, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.14, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 102.99, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 90.87, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.68, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.39, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 113.89, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 94.87, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 66.15, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.32, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 90.87, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 106.62, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 70.27, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 66.15, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "POSACONAZOLE 300 MG/16.7ML IV SOLN", "drug_information": { "unit": "16.700000", "type": "UN" }, "code_information": [ { "code": "42023019501", "type": "NDC" } ], "standard_charges": [ { "minimum": 141.14, "maximum": 1158.0, "gross_charge": 500.85, "discounted_cash": 275.47, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 290.49, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 273.46, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 434.74, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 145.75, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 240.41, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 300.01, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 299.51, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 470.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 440.75, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 141.14, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 425.72, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 375.64, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 176.45, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 340.58, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 470.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 392.17, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 273.46, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 398.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 375.64, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 440.75, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 290.49, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 273.46, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "POSACONAZOLE 40 MG/ML PO SUSP", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "00254101636", "type": "NDC" } ], "standard_charges": [ { "minimum": 29.81, "maximum": 99.45, "gross_charge": 105.8, "discounted_cash": 58.19, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.36, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 57.77, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 84.64, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 89.61, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.79, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.78, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.37, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.27, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 99.45, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.1, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.81, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 89.93, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 79.35, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.27, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 71.94, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 99.45, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.84, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 57.77, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 84.11, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 79.35, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.1, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.36, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 57.77, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "POT & SOD CIT-CIT AC 550-500-334 MG/5ML PO SOLN", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "58657031116", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "POT & SOD CIT-CIT AC 550-500-334 MG/5ML PO SYRP", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "60258000216", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "POTASSIUM & SODIUM PHOSPHATES 280-160-250 MG PO PACK", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60258000601", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "POTASSIUM ACETATE 2 MEQ/ML IV SOLN", "drug_information": { "unit": "20.000000", "type": "UN" }, "code_information": [ { "code": "00409818301", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 1158.0, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.72, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "POTASSIUM ALUM POWD", "drug_information": { "unit": "10.000000", "type": "GR" }, "code_information": [ { "code": "24357030030", "type": "NDC" } ], "standard_charges": [ { "minimum": 17.87, "maximum": 1158.0, "gross_charge": 63.4, "discounted_cash": 34.87, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.77, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.62, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.03, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.45, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.43, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.98, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.91, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.79, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.87, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 53.89, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.55, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.34, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.11, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.64, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.62, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.4, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.55, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.79, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.77, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.62, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "POTASSIUM CHLORIDE 0.1 MEQ/ML INTRAVIA (PERIPHERAL)", "drug_information": { "unit": "100.000000", "type": "UN" }, "code_information": [ { "code": "00338070948", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "POTASSIUM CHLORIDE 0.1 MEQ/ML SYRINGE (PERIPHERAL)", "drug_information": { "unit": "100.000000", "type": "UN" }, "code_information": [ { "code": "00338070948_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "POTASSIUM CHLORIDE 0.4 MEQ/ML SYRINGE (PEDS) FROM IVAS MAKER", "drug_information": { "unit": "20.000000", "type": "UN" }, "code_information": [ { "code": "08252000148", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "POTASSIUM CHLORIDE 0.4 MEQ/ML SYRINGE (PEDS) FROM IVAS MAKER CARDIAC", "drug_information": { "unit": "20.000000", "type": "UN" }, "code_information": [ { "code": "08252000148_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "POTASSIUM CHLORIDE 10 MEQ/100ML IV SOLN RTU", "drug_information": { "unit": "100.000000", "type": "UN" }, "code_information": [ { "code": "00338070948_3", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "POTASSIUM CHLORIDE 10 MEQ/50ML IV SOLN RTU", "drug_information": { "unit": "50.000000", "type": "UN" }, "code_information": [ { "code": "00338070541", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "POTASSIUM CHLORIDE 10 MEQ/7.5 ML ORAL SOLUTION", "drug_information": { "unit": "7.500000", "type": "UN" }, "code_information": [ { "code": "0121146515", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "POTASSIUM CHLORIDE 2 MEQ/ML IV SOLN", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "63323096510", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "POTASSIUM CHLORIDE 2 MEQ/ML IV SOLN (OBGYN ONLY)", "drug_information": { "unit": "20.000000", "type": "UN" }, "code_information": [ { "code": "63323096510_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "POTASSIUM CHLORIDE 20 MEQ/100ML RTU", "drug_information": { "unit": "100.000000", "type": "UN" }, "code_information": [ { "code": "00338070548", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "POTASSIUM CHLORIDE 20 MEQ/15ML (10%) PO SOLN", "drug_information": { "unit": "15.000000", "type": "UN" }, "code_information": [ { "code": "60687062871", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.21, "maximum": 4.02, "gross_charge": 4.28, "discounted_cash": 2.35, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.48, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.34, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.42, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.63, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.25, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.05, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.56, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.56, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.02, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.77, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.21, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.64, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.21, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.51, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.91, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.02, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.35, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.34, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.21, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.77, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.48, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.34, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "POTASSIUM CHLORIDE 20 MEQ/15ML (10%) PO SOLN CCU", "drug_information": { "unit": "15.000000", "type": "UN" }, "code_information": [ { "code": "60687062871_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.21, "maximum": 4.02, "gross_charge": 4.28, "discounted_cash": 2.35, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.48, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.34, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.42, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.63, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.25, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.05, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.56, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.56, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.02, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.77, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.21, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.64, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.21, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.51, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.91, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.02, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.35, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.34, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.21, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.77, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.48, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.34, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "POTASSIUM CHLORIDE 20 MEQ/50 ML (0.4 MEQ/ML) SYR-RTU", "drug_information": { "unit": "50.000000", "type": "UN" }, "code_information": [ { "code": "00338070341", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "POTASSIUM CHLORIDE 20 MEQ/50ML RTU", "drug_information": { "unit": "50.000000", "type": "UN" }, "code_information": [ { "code": "00338070341_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "POTASSIUM CHLORIDE 20 MEQ/50ML RTU CCU", "drug_information": { "unit": "50.000000", "type": "UN" }, "code_information": [ { "code": "00338070341_3", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "POTASSIUM CHLORIDE CRYS ER 20 MEQ PO TBCR", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00245531901", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "POTASSIUM CHLORIDE ER 10 MEQ PO TBCR", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00245531689", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "POTASSIUM CHLORIDE ER 10 MEQ PO TBCR CCU", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00245531689_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "POTASSIUM CHLORIDE ER 8 MEQ PO TBCR", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00245531501", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "POTASSIUM CITRATE ER 10 MEQ (1080 MG) PO TBCR", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00178061001", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.36, "maximum": 4.55, "gross_charge": 4.84, "discounted_cash": 2.66, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.81, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.64, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.87, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.1, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.9, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.55, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.26, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.36, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.11, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.63, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.71, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.29, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.55, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.79, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.64, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.85, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.63, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.26, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.81, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.64, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "POTASSIUM CITRATE-CITRIC ACID 1100-334 MG/5ML PO SOLN", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "00121067616", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "POTASSIUM CITRATE-CITRIC ACID 3300-1002 MG PO PACK", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60258000501", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "POTASSIUM CL IN DEXTROSE 5% 20 MEQ/L IV SOLN", "drug_information": { "unit": "1000.000000", "type": "UN" }, "code_information": [ { "code": "00338068304", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "POTASSIUM IODIDE (EXPECTORANT) 1 GM/ML PO SOLN", "drug_information": { "unit": "0.250000", "type": "UN" }, "code_information": [ { "code": "71740011230", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.29, "maximum": 7.62, "gross_charge": 8.11, "discounted_cash": 4.46, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.7, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.43, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.49, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.87, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.36, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.89, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.86, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.85, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.62, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.14, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.29, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.89, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.08, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.86, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.51, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.62, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.35, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.43, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.08, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.14, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.7, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.43, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "POTASSIUM PHOSPHATE 3 MMOL/ML (IV FOR PO)", "drug_information": { "unit": "15.000000", "type": "UN" }, "code_information": [ { "code": "00409729501", "type": "NDC" } ], "standard_charges": [ { "minimum": 8.7, "maximum": 29.01, "gross_charge": 30.86, "discounted_cash": 16.97, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.9, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.85, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.69, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.14, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.98, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.81, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.49, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.45, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.01, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.16, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.7, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.23, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.15, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.87, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.98, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.01, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.16, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.85, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.53, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.15, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.16, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.9, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.85, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "POTASSIUM PHOSPHATES 150 MMOLE/50ML IV SOLN", "drug_information": { "unit": "50.000000", "type": "UN" }, "code_information": [ { "code": "65219005629", "type": "NDC" } ], "standard_charges": [ { "minimum": 43.16, "maximum": 1158.0, "gross_charge": 153.16, "discounted_cash": 84.24, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.83, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 83.63, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 132.94, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 44.57, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 73.52, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 91.74, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 91.59, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 143.97, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 134.78, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.16, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 130.19, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 114.87, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 53.96, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 104.15, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 143.97, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 119.92, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 83.63, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 121.76, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 114.87, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 134.78, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.83, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 83.63, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "POTASSIUM PHOSPHATES 3 MMOL/ML IV SOLN (MULTI-GPI)", "drug_information": { "unit": "15.000000", "type": "UN" }, "code_information": [ { "code": "00409729501_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 1158.0, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.72, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "POTASSIUM PHOSPHATES 45 MMOLE/15ML IV SOLN", "drug_information": { "unit": "15.000000", "type": "UN" }, "code_information": [ { "code": "00409729501_3", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 1158.0, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.72, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "POTASSIUM PHOSPHATES(66 MEQ K) 45 MMOLE/15ML IV SOLN", "drug_information": { "unit": "15.000000", "type": "UN" }, "code_information": [ { "code": "00409729501_4", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 1158.0, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.72, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "POVIDONE-IODINE 10 % EX OINT", "drug_information": { "unit": "28.400000", "type": "GR" }, "code_information": [ { "code": "00536127180", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "POVIDONE-IODINE 10 % EX SOLN", "drug_information": { "unit": "236.000000", "type": "UN" }, "code_information": [ { "code": "00904110309", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.68, "maximum": 5.59, "gross_charge": 5.95, "discounted_cash": 3.27, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.45, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.25, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.76, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.04, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.73, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.86, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.56, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.56, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.59, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.24, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.68, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.06, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.46, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.1, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.05, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.59, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.66, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.25, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.73, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.46, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.24, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.45, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.25, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "POVIDONE-IODINE 5 % OP SOLN", "drug_information": { "unit": "30.000000", "type": "UN" }, "code_information": [ { "code": "00065041130", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "POVIDONE-IODINE 7.5 % EX SOLN", "drug_information": { "unit": "118.000000", "type": "UN" }, "code_information": [ { "code": "67618015104", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.78, "maximum": 9.26, "gross_charge": 9.85, "discounted_cash": 5.42, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.71, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.38, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.88, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.34, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.87, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.73, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.9, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.26, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.67, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.78, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.37, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.39, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.47, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.7, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.26, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.71, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.38, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.83, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.39, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.67, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.71, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.38, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PRALATREXATE 20 MG/ML IV SOLN", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "72893000301", "type": "NDC" } ], "standard_charges": [ { "minimum": 204.08, "maximum": 20086.16, "gross_charge": 21368.25, "discounted_cash": 11752.54, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 12393.59, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 204.08, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17094.6, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 18098.91, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6218.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10256.76, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 12799.58, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 11394.0, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20086.16, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 18804.06, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 6021.57, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 18163.01, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16026.19, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 7528.03, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 14530.41, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 20086.16, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 16731.34, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 275.51, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 15189.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16026.19, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 18804.06, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 12393.59, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 204.08, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "PRALIDOXIME CHLORIDE 1 G IV SOLR", "drug_information": { "unit": "1.000000", "type": "GR" }, "code_information": [ { "code": "60977014101", "type": "NDC" } ], "standard_charges": [ { "minimum": 66.39, "maximum": 221.45, "gross_charge": 235.58, "discounted_cash": 129.57, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 136.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 128.63, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 188.46, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 199.54, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 68.55, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 113.08, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 141.11, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 140.88, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 221.45, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 207.31, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 66.39, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 200.24, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 176.69, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.99, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 160.19, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 221.45, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 184.46, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 128.63, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 187.29, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 176.69, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 207.31, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 136.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 128.63, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PRAMIPEXOLE DIHYDROCHLORIDE 0.125 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "1366809105", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PRAMIPEXOLE DIHYDROCHLORIDE 0.25 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687057001", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PRAMIPEXOLE DIHYDROCHLORIDE 0.5 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687058121", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PRAMIPEXOLE DIHYDROCHLORIDE 1 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687059221", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PRAMOXINE HCL (PERIANAL) 1 % EX FOAM", "drug_information": { "unit": "15.000000", "type": "GR" }, "code_information": [ { "code": "00037682315", "type": "NDC" } ], "standard_charges": [ { "minimum": 58.59, "maximum": 195.45, "gross_charge": 207.93, "discounted_cash": 114.36, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 120.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 113.53, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 166.34, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 176.12, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.51, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 99.81, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 124.55, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 124.34, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 195.45, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 182.98, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 58.59, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 176.74, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 155.95, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 73.25, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 141.39, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 195.45, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 162.81, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 113.53, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 165.3, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 155.95, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 182.98, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 120.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 113.53, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PRAMOXINE HCL 1 % EX LOTN", "drug_information": { "unit": "118.000000", "type": "UN" }, "code_information": [ { "code": "00496074804", "type": "NDC" } ], "standard_charges": [ { "minimum": 10.45, "maximum": 34.86, "gross_charge": 37.08, "discounted_cash": 20.39, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.51, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.25, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.66, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.41, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.79, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.21, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.17, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.86, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.63, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.45, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.52, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.81, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.06, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.21, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.86, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.03, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.25, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.48, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.81, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.63, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.51, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.25, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PRAMOXINE-CALAMINE 1-8 % EX LOTN", "drug_information": { "unit": "177.000000", "type": "UN" }, "code_information": [ { "code": "00395042096", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.11, "maximum": 7.03, "gross_charge": 7.48, "discounted_cash": 4.11, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.34, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.08, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.98, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.34, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.59, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.48, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.47, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.03, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.58, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.11, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.36, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.61, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.64, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.09, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.03, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.86, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.08, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.95, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.61, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.58, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.34, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.08, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PRASUGREL 10 MG - 6 TAB LOADING DOSE ONLY", "drug_information": { "unit": "6.000000", "type": "UN" }, "code_information": [ { "code": "08252000171", "type": "NDC" } ], "standard_charges": [ { "minimum": 3.15, "maximum": 10.52, "gross_charge": 11.19, "discounted_cash": 6.15, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.49, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.11, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.95, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.48, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.26, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.37, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.7, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.69, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.85, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.15, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.51, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.39, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.94, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.61, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.76, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.11, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.9, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.39, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.85, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.49, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.11, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PRASUGREL HCL 10 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "1672927310", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PRASUGREL HCL 5 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60505464203", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PRAVASTATIN SODIUM 10 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687016901", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PRAVASTATIN SODIUM 20 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687017801", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PRAVASTATIN SODIUM 40 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687019001", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PRAZIQUANTEL 600 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "49884023183", "type": "NDC" } ], "standard_charges": [ { "minimum": 43.72, "maximum": 145.84, "gross_charge": 155.15, "discounted_cash": 85.33, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 89.99, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 84.71, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 124.12, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 131.41, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.15, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.47, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 92.93, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 92.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 145.84, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 136.53, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.72, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 131.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 116.36, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.66, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 105.5, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 145.84, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 121.48, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 84.71, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 123.34, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 116.36, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 136.53, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 89.99, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 84.71, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Prcrd drg 6yr+ w/o cgen car", "code_information": [ { "code": "33017", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 15597.12, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 29435.24, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 29435.24, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PREDNISOLONE ACETATE 0.12 % OP SUSP", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "11980017410", "type": "NDC" } ], "standard_charges": [ { "minimum": 327.52, "maximum": 1092.51, "gross_charge": 1162.24, "discounted_cash": 639.23, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 674.1, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 634.58, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 929.79, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 984.42, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 338.21, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 557.88, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 696.18, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 695.02, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1092.51, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1022.77, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 327.52, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 987.9, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 871.68, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 409.46, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 790.32, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1092.51, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 910.03, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 634.58, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 923.98, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 871.68, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1022.77, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 674.1, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 634.58, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PREDNISOLONE ACETATE 1 % OP SUSP", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "60758011905", "type": "NDC" } ], "standard_charges": [ { "minimum": 19.97, "maximum": 66.63, "gross_charge": 70.88, "discounted_cash": 38.98, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.11, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.7, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 56.7, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.04, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.63, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.02, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.46, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 66.63, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 62.37, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.97, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.25, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 53.16, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.97, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 48.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 66.63, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.5, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.7, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 56.35, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 53.16, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 62.37, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.11, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.7, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PREDNISOLONE SODIUM PHOSPHATE 15 MG/5ML PO SOLN", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "R0121075908", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PREDNISOLONE SODIUM PHOSPHATE 6.7 (5 BASE) MG/5ML PO SOLN", "drug_information": { "unit": "120.000000", "type": "UN" }, "code_information": [ { "code": "13925016604", "type": "NDC" } ], "standard_charges": [ { "minimum": 34.59, "maximum": 115.39, "gross_charge": 122.75, "discounted_cash": 67.51, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 71.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 67.02, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 98.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.97, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.72, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 58.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 73.53, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 73.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 115.39, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 108.02, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.59, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 104.34, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 92.06, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.24, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 83.47, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 115.39, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.11, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 67.02, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 97.59, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 92.06, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 108.02, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 71.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 67.02, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PREDNISONE 1 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "1013577401", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PREDNISONE 10 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "1013577701", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PREDNISONE 2.5 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "1013577501", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PREDNISONE 20 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "R0054001825", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": 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88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PREDNISONE 5 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "1013577601", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 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of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 479.65, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 452.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 530.93, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 349.93, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 329.42, 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charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.71, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.13, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.28, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.98, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.34, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.1, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.17, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.98, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" }, { "minimum": 6.15, "maximum": 20.52, "gross_charge": 21.83, "discounted_cash": 12.01, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.66, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.92, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.46, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", 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"standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.69, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.84, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.09, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.92, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.35, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.37, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.21, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.66, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.92, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PREDNISONE 5 MG/5ML PO SOLN (EP ORAL)", "drug_information": { "unit": "500.000000", "type": "UN" }, "code_information": [ { "code": "00054372263_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 170.02, "maximum": 567.13, "gross_charge": 603.33, "discounted_cash": 331.83, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 349.93, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 329.42, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 482.66, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 511.02, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 175.57, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 289.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 361.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 360.79, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 567.13, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 530.93, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 170.02, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 512.83, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 452.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 212.55, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 410.26, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 567.13, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 472.41, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 329.42, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 479.65, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 452.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 530.93, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 349.93, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 329.42, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PREDNISONE 50 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "1013577901", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PREGABALIN 100 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687050601", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.25, "maximum": 7.52, "gross_charge": 8.0, "discounted_cash": 4.4, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.4, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.78, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.33, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.84, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.79, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.25, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.8, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.82, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.44, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.26, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.36, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PREGABALIN 150 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687051701", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.25, "maximum": 7.52, "gross_charge": 8.0, "discounted_cash": 4.4, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.4, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.78, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.33, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.84, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.79, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.25, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.8, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.82, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.44, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.26, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.36, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PREGABALIN 20 MG/ML PO SOLN", "drug_information": { "unit": "473.000000", "type": "UN" }, "code_information": [ { "code": "67877045747", "type": "NDC" } ], "standard_charges": [ { "minimum": 35.65, "maximum": 118.91, "gross_charge": 126.5, "discounted_cash": 69.58, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 73.37, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 69.07, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 101.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 107.15, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.81, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.72, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.77, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.65, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 118.91, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 111.32, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.65, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 107.53, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 94.88, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 44.57, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.02, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 118.91, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 99.05, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 69.07, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 100.57, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 94.88, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 111.32, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 73.37, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 69.07, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PREGABALIN 25 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687047301", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.25, "maximum": 7.52, "gross_charge": 8.0, "discounted_cash": 4.4, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.4, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.78, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.33, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.84, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.79, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.25, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.8, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.82, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.44, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.26, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.36, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PREGABALIN 50 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687048401", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.25, "maximum": 7.52, "gross_charge": 8.0, "discounted_cash": 4.4, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.4, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.78, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.33, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.84, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.79, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.25, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.8, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.82, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.44, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.26, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.36, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PREGABALIN 75 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687049501", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.25, "maximum": 7.52, "gross_charge": 8.0, "discounted_cash": 4.4, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.4, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.78, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.33, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.84, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.79, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.25, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.8, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.82, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.44, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.26, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.36, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PREMASOL 10 % IV SOLN", "drug_information": { "unit": "1000.000000", "type": "UN" }, "code_information": [ { "code": "00338113004", "type": "NDC" } ], "standard_charges": [ { "minimum": 98.73, "maximum": 1158.0, "gross_charge": 350.36, "discounted_cash": 192.7, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 203.21, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 191.3, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 304.11, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 101.95, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 168.17, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 209.87, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 209.52, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 329.34, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 308.32, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 98.73, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 297.81, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 262.77, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 123.43, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 238.24, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 329.34, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 274.33, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 191.3, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 278.54, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 262.77, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 308.32, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 203.21, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 191.3, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PRENATAL VITAMIN TABS (MULTI-GPI)", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "77333071510", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Prepare penis study", "code_information": [ { "code": "54230", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 1567.36, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 2844.01, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 2844.01, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Prepare sperm duct x-ray", "code_information": [ { "code": "55300", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 13927.32, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 25271.36, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 25271.36, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Preputial stretching", "code_information": [ { "code": "54450", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 179.27, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 132.79, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 11421.51, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 20724.51, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 179.27, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 20724.51, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Prim art m-thrmbc 1st vsl", "code_information": [ { "code": "37184", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 13235.9, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 9804.37, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 42861.75, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 77773.41, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 13235.9, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 77773.41, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PRIMAQUINE PHOSPHATE 26.3 (15 BASE) MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00024159601", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.3, "maximum": 4.35, "gross_charge": 4.63, "discounted_cash": 2.55, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.69, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.53, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.7, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.92, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.35, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.22, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.77, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.77, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.35, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.07, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.3, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.94, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.47, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.63, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.15, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.35, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.63, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.53, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.68, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.47, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.07, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.69, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.53, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PRIMIDONE 250 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68084020301", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PRIMIDONE 50 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68084020201", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PRISMASOL B22GK 4/0 22-4 MEQ/L EC SOLN", "drug_information": { "unit": "5000.000000", "type": "UN" }, "code_information": [ { "code": "24571011106", "type": "NDC" } ], "standard_charges": [ { "minimum": 28.18, "maximum": 1158.0, "gross_charge": 100.0, "discounted_cash": 55.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 58.0, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.6, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.8, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.1, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 48.0, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.9, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.8, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 94.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.18, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 85.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.23, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 68.0, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 94.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 78.3, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.6, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 79.5, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 58.0, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.6, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PRISMASOL BGK 0/2.5 32-2.5 MEQ/L EC SOLN", "drug_information": { "unit": "5000.000000", "type": "UN" }, "code_information": [ { "code": "24571010806", "type": "NDC" } ], "standard_charges": [ { "minimum": 28.18, "maximum": 1158.0, "gross_charge": 100.0, "discounted_cash": 55.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 58.0, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.6, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.8, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.1, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 48.0, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.9, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.8, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 94.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.18, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 85.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.23, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 68.0, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 94.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 78.3, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.6, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 79.5, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 58.0, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.6, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PRISMASOL BGK 2/0 32-2 MEQ/L EC SOLN", "drug_information": { "unit": "5000.000000", "type": "UN" }, "code_information": [ { "code": "24571010206", "type": "NDC" } ], "standard_charges": [ { "minimum": 28.18, "maximum": 1158.0, "gross_charge": 100.0, "discounted_cash": 55.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 58.0, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.6, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.8, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.1, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 48.0, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.9, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.8, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 94.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.18, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 85.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.23, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 68.0, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 94.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 78.3, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.6, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 79.5, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 58.0, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.6, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PRISMASOL BGK 4/0/1.2 32-4-1.2 MEQ/L EC SOLN", "drug_information": { "unit": "5000.000000", "type": "UN" }, "code_information": [ { "code": "24571011406", "type": "NDC" } ], "standard_charges": [ { "minimum": 28.18, "maximum": 1158.0, "gross_charge": 100.0, "discounted_cash": 55.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 58.0, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.6, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.8, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.1, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 48.0, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.9, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.8, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 94.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.18, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 85.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.23, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 68.0, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 94.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 78.3, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.6, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 79.5, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 58.0, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.6, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PRISMASOL BGK 4/2.5 32-4-2.5 MEQ/L EC SOLN", "drug_information": { "unit": "5000.000000", "type": "UN" }, "code_information": [ { "code": "24571010506", "type": "NDC" } ], "standard_charges": [ { "minimum": 28.18, "maximum": 1158.0, "gross_charge": 100.0, "discounted_cash": 55.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 58.0, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.6, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.8, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.1, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 48.0, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.9, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.8, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 94.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.18, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 85.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.23, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 68.0, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 94.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 78.3, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.6, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 79.5, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 58.0, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.6, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PRISMASOL BGK 4/2.5 REPLACEMENT SOLUTION (INTRA-OP CRRT ONLY)", "drug_information": { "unit": "5000.000000", "type": "UN" }, "code_information": [ { "code": "24571010506_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 28.18, "maximum": 1158.0, "gross_charge": 100.0, "discounted_cash": 55.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 58.0, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.6, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.8, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.1, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 48.0, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.9, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.8, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 94.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.18, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 85.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.23, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 68.0, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 94.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 78.3, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.6, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 79.5, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 58.0, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.6, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Probe nasolacrimal duct", "code_information": [ { "code": "68810", "type": "HCPCS" }, { "code": "68811", "type": "HCPCS" }, { "code": "68815", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1719.62, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 163.22, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1273.8, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 2066.16, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 3749.09, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 220.34, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1719.62, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 3749.09, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Probe nl duct w/balloon", "code_information": [ { "code": "68816", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1719.62, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1273.8, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 2013.76, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 3713.09, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1719.62, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 3713.09, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PROBENECID 500 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00591534701", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PROCAINAMIDE 50 MG/ML SUSPENSION", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "P0409190301", "type": "NDC" } ], "standard_charges": [ { "minimum": 8.81, "maximum": 29.38, "gross_charge": 31.25, "discounted_cash": 17.19, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.13, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.47, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.09, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.0, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.72, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.69, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.38, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.5, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.81, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.56, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.44, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.01, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.25, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.38, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.47, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.84, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.44, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.5, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.13, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PROCAINAMIDE HCL 100 MG/ML IJ SOLN", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "00409190201", "type": "NDC" } ], "standard_charges": [ { "minimum": 48.87, "maximum": 402.51, "gross_charge": 173.43, "discounted_cash": 95.39, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 100.59, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 298.15, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 138.74, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 146.9, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.47, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 83.25, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.88, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.71, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 163.02, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 152.62, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 48.87, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 147.42, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 130.07, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.1, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 117.93, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 163.02, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 135.8, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 402.51, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 137.88, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 130.07, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 152.62, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 100.59, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 298.15, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "PROCAINAMIDE HCL 500 MG/ML IJ SOLN", "drug_information": { "unit": "2.000000", "type": "UN" }, "code_information": [ { "code": "14789090002", "type": "NDC" } ], "standard_charges": [ { "minimum": 298.15, "maximum": 1941.1, "gross_charge": 2065.0, "discounted_cash": 1135.75, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1197.7, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 298.15, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1652.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1749.06, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 600.92, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 991.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1236.94, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 1234.87, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1941.1, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1817.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 581.92, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1755.25, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1548.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 727.5, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1404.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1941.1, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1616.9, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 402.51, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1641.68, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1548.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1817.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1197.7, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 298.15, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "PROCARBAZINE HCL 50 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "54482005401", "type": "NDC" } ], "standard_charges": [ { "minimum": 100.05, "maximum": 333.75, "gross_charge": 355.05, "discounted_cash": 195.28, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 205.93, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 193.86, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 284.04, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 300.73, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.32, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 170.42, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 212.67, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 212.32, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 333.75, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 312.44, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 100.05, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 301.79, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 266.29, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 125.08, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 241.43, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 333.75, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 278.0, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 193.86, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 282.26, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 266.29, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 312.44, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 205.93, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 193.86, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PROCHLORPERAZINE 25 MG RE SUPP", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00574722612", "type": "NDC" } ], "standard_charges": [ { "minimum": 4.52, "maximum": 15.07, "gross_charge": 16.03, "discounted_cash": 8.82, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.3, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.75, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.82, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.58, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.66, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.69, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.6, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.59, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.07, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.11, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.52, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.63, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.02, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.65, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.9, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.07, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.55, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.75, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.74, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.02, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.11, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.3, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.75, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PROCHLORPERAZINE EDISYLATE 10 MG/2ML IJ SOLN", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "25021079002", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PROCHLORPERAZINE MALEATE 10 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "50268068515", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PROCHLORPERAZINE MALEATE 5 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "50268068415", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Proctosigmoidoscopy dx", "code_information": [ { "code": "45300", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 672.02, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 497.79, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 30369.12, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 55121.94, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 672.02, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 55121.94, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Proctosigmoidoscopy w/bx", "code_information": [ { "code": "45305", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 869.1, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 643.78, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 8923.52, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 18077.81, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 869.1, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 18077.81, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PROGESTERONE 100 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "70700016201", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PROGESTERONE 100 MG VA INST", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "55566650003", "type": "NDC" } ], "standard_charges": [ { "minimum": 9.05, "maximum": 30.17, "gross_charge": 32.1, "discounted_cash": 17.66, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.62, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.53, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.68, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.19, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.34, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.41, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.23, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.17, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.25, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.05, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.29, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.08, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.31, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.83, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.17, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.53, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.52, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.08, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.25, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.62, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.53, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PROGESTERONE 200 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "70700016301", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PROGESTERONE 200 MG VA SUPP", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "65628006301", "type": "NDC" } ], "standard_charges": [ { "minimum": 3.98, "maximum": 13.26, "gross_charge": 14.11, "discounted_cash": 7.76, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.18, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.7, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.29, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.95, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.11, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.77, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.45, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.44, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.26, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.42, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.98, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.99, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.58, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.97, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.59, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.26, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.05, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.7, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.22, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.58, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.42, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.18, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.7, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PROGESTERONE 50 MG/ML IM OIL", "drug_information": { "unit": "0.100000", "type": "UN" }, "code_information": [ { "code": "55150030610", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PROMETHAZINE 6.25 MG IN 50 ML NS IVPB (BATCHED)", "drug_information": { "unit": "50.000000", "type": "UN" }, "code_information": [ { "code": "08252457401", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PROMETHAZINE HCL 12.5 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687066001", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PROMETHAZINE HCL 12.5 MG RE SUPP", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00713053612", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.59, "maximum": 5.3, "gross_charge": 5.64, "discounted_cash": 3.1, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.27, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.08, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.51, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.78, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.71, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.38, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.37, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.3, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.96, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.59, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.79, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.23, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.99, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.84, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.3, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.42, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.08, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.48, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.23, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.96, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.27, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.08, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PROMETHAZINE HCL 25 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68084015501", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PROMETHAZINE HCL 25 MG RE SUPP", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00713052612", "type": "NDC" } ], "standard_charges": [ { "minimum": 3.17, "maximum": 10.57, "gross_charge": 11.24, "discounted_cash": 6.18, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.52, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.14, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.99, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.52, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.27, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.4, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.73, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.72, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.57, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.89, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.17, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.55, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.43, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.96, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.64, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.57, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.8, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.14, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.94, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.43, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.89, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.52, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.14, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PROMETHAZINE HCL 25 MG/ML IJ SOLN", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "39822552503", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PROMETHAZINE HCL 50 MG RE SUPP", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00713013212", "type": "NDC" } ], "standard_charges": [ { "minimum": 14.71, "maximum": 49.08, "gross_charge": 52.21, "discounted_cash": 28.72, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.28, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.51, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.77, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 44.22, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.19, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.06, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.27, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.22, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.08, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.94, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.71, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 44.38, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.16, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.39, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.5, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.08, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.88, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.51, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.51, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.16, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.94, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.28, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.51, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PROMETHAZINE HCL 6.25 MG/5ML PO SOLN", "drug_information": { "unit": "473.000000", "type": "UN" }, "code_information": [ { "code": "27808005102", "type": "NDC" } ], "standard_charges": [ { "minimum": 6.62, "maximum": 22.07, "gross_charge": 23.48, "discounted_cash": 12.91, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.62, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.82, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.78, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.89, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.83, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.06, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.04, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.07, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.66, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.62, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.96, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.61, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.27, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.97, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.07, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.38, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.82, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.67, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.61, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.66, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.62, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.82, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PROMETHAZINE-CODEINE 6.25-10 MG/5ML PO SYRP", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "1785680405", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.25, "maximum": 7.52, "gross_charge": 8.0, "discounted_cash": 4.4, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.4, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.78, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.33, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.84, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.79, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.25, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.8, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.82, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.44, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.26, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.36, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PROPAFENONE 20MG/ML SUSPENSION", "drug_information": { "unit": "7.500000", "type": "UN" }, "code_information": [ { "code": "P0603544800", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PROPAFENONE HCL 150 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687070901", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PROPAFENONE HCL ER 425 MG PO CP12", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "69680013260", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PROPARACAINE HCL 0.5 % OP SOLN", "drug_information": { "unit": "15.000000", "type": "UN" }, "code_information": [ { "code": "24208073006", "type": "NDC" } ], "standard_charges": [ { "minimum": 18.47, "maximum": 61.6, "gross_charge": 65.53, "discounted_cash": 36.04, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.01, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.78, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.42, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.07, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.45, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.25, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.19, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 57.67, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.47, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.7, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.15, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 44.56, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 51.31, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.78, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.1, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.15, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 57.67, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.01, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.78, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Proph rta dtchmnt pc", "code_information": [ { "code": "67145", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 404.37, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 299.54, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 14547.86, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 26397.31, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 404.37, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 26397.31, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PROPOFOL 10 MG/ML IV EMUL 100 ML VIAL (BULK CHARGE)", "drug_information": { "unit": "100.000000", "type": "UN" }, "code_information": [ { "code": "63323026965", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PROPOFOL 10 MG/ML IV EMUL 20 ML VIAL (BULK CHARGE)", "drug_information": { "unit": "20.000000", "type": "UN" }, "code_information": [ { "code": "63323026929", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PROPOFOL 100 MG/10ML IV EMUL", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "63323026910", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PROPOFOL 1000 MG/100ML IV EMUL", "drug_information": { "unit": "100.000000", "type": "UN" }, "code_information": [ { "code": "63323026965_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PROPOFOL 200 MG/20ML IV EMUL", "drug_information": { "unit": "20.000000", "type": "UN" }, "code_information": [ { "code": "63323026929_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PROPOFOL 500 MG/50ML IV EMUL", "drug_information": { "unit": "60.000000", "type": "UN" }, "code_information": [ { "code": "63323026950", "type": "NDC" } ], "standard_charges": [ { "minimum": 13.53, "maximum": 45.12, "gross_charge": 48.0, "discounted_cash": 26.4, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.84, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.21, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.4, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.66, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.97, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.04, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.75, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.7, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.12, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.24, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.53, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.8, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.91, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.64, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.12, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.58, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.21, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.16, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.24, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.84, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.21, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PROPOFOL FIXED RATE INFUSION 10 MG/ML", "drug_information": { "unit": "100.000000", "type": "UN" }, "code_information": [ { "code": "63323026965_3", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PROPOFOL TITRATABLE RATE INFUSION 10 MG/ML", "drug_information": { "unit": "100.000000", "type": "UN" }, "code_information": [ { "code": "63323026965_4", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PROPRANOLOL HCL 1 MG/ML IV SOLN", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "63323060401", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PROPRANOLOL HCL 10 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "5009001461", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PROPRANOLOL HCL 20 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "50268066315", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", 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"standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", 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{ "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PROPRANOLOL HCL 20 MG/5ML PO SOLN", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "R0054372763", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PROPRANOLOL HCL 20 MG/5ML PO SUSP", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "R6068730601", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PROPRANOLOL HCL 40 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687060901", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PROPRANOLOL HCL 80 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00591555701", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", 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{ "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PROPRANOLOL HCL ER 160 MG PO CP24", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00228278111", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.04, "maximum": 6.8, "gross_charge": 7.23, "discounted_cash": 3.98, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.19, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.95, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.78, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.12, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.1, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.47, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.33, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.32, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.36, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.04, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.15, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.42, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.55, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.92, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.66, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.95, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.75, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.42, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.36, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.19, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.95, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PROPRANOLOL HCL ER 60 MG PO CP24", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687021501", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PROPRANOLOL HCL ER 80 MG PO CP24", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687022601", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PROPYLENE GLYCOL LIQD", "drug_information": { "unit": "500.000000", "type": "UN" }, "code_information": [ { "code": "38779051008", "type": "NDC" } ], "standard_charges": [ { "minimum": 12.05, "maximum": 40.19, "gross_charge": 42.75, "discounted_cash": 23.51, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.34, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.21, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.44, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.52, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.61, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.56, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.19, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.62, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.05, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.34, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.06, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.06, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.07, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.19, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.47, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.34, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.99, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.06, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.62, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.34, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PROPYLTHIOURACIL 200 MG RECTAL SUPP", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "08252000003", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.25, "maximum": 4.15, "gross_charge": 4.42, "discounted_cash": 2.43, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.56, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.41, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.54, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.74, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.29, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.12, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.65, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.64, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.15, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.89, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.25, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.32, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.56, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.01, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.15, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.46, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.41, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.51, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.32, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.89, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.56, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.41, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PROPYLTHIOURACIL 5 MG/ML ORAL SUSPENSION", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "08252000143", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PROPYLTHIOURACIL 50 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68084096425", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.25, "maximum": 4.15, "gross_charge": 4.42, "discounted_cash": 2.43, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.56, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.41, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.54, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.74, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.29, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.12, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.65, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.64, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.15, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.89, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.25, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.32, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.56, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.01, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.15, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.46, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.41, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.51, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.32, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.89, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.56, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.41, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Prostate laser enucleation", "code_information": [ { "code": "52649", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 3747.14, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2775.66, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 22494.57, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 40816.76, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3747.14, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 40816.76, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Prostate saturation sampling", "code_information": [ { "code": "55706", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2542.24, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1883.14, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 6463.15, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 11727.49, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2542.24, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 11727.49, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Prostatectomy (turp)", "code_information": [ { "code": "52601", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 3747.14, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2775.66, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 14911.0, "methodology": "percent of total billed charges" }, { "payer_name": 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"inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", 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"additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", 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of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 62.76, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.56, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.57, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 44.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 44.31, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 69.65, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.21, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.88, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 62.99, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.58, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.11, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.39, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 69.65, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 58.02, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": 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billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.46, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PROTAMINE SULFATE 10 MG/ML IV SOLN 5 ML VIAL (BULK CHARGE)", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "63323022905_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PROTHROMBIN COMPLEX CONC HUMAN 1000 UNITS IV KIT", "drug_information": { "unit": "40.000000", "type": "UN" }, "code_information": [ { "code": "63833038702_5", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.22, "maximum": 4634.2, "gross_charge": 4930.0, "discounted_cash": 2711.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2859.4, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.22, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3944.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4175.71, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1434.63, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2366.4, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2953.07, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2948.14, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4634.2, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4338.4, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1389.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4190.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3697.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1736.84, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All 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"additional_payer_notes": "N/A", "standard_charge_dollar": 1.22, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "PROTHROMBIN COMPLEX CONC HUMAN 500 UNITS IV KIT", "drug_information": { "unit": "40.000000", "type": "UN" }, "code_information": [ { "code": "63833038602_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 1845.79, "maximum": 6157.0, "gross_charge": 6550.0, "discounted_cash": 3602.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3799.0, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3576.3, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan 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billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3799.0, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3576.3, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PROTHROMBIN COMPLEX CONC HUMAN 500 UNITS IV KIT|DISCARDED DRUG NOT ADMINISTERED", "drug_information": { "unit": "40.000000", "type": "UN" }, "code_information": [ { "code": "63833038602", "type": "NDC" } ], "standard_charges": [ { "minimum": 1826.06, "maximum": 6091.2, "gross_charge": 6480.0, "discounted_cash": 3564.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 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"standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2848.89, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4699.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5864.21, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 5854.42, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9202.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8615.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2758.82, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8321.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7342.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3449.02, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6657.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 9202.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7665.57, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5345.34, 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"additional_payer_notes": "N/A", "standard_charge_dollar": 5345.34, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PROTHROMBIN COMPLEX CONC HUMAN IVPB FAILSAFE|DISCARDED DRUG NOT ADMINISTERED", "drug_information": { "unit": "60.000000", "type": "UN" }, "code_information": [ { "code": "63833038602_6", "type": "NDC" } ], "standard_charges": [ { "minimum": 2739.1, "maximum": 9136.8, "gross_charge": 9720.0, "discounted_cash": 5346.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5637.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5307.12, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7776.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8232.84, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2828.52, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4665.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5822.28, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 5812.56, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9136.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8553.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2739.1, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8262.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7290.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3424.36, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6609.6, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 9136.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7610.76, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5307.12, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7727.4, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7290.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8553.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5637.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5307.12, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Prp i/hern init block >5 yr", "code_information": [ { "code": "49507", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2601.27, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1926.87, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 14129.57, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 25638.35, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2601.27, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 25638.35, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Prp i/hern init reduc >5 yr", "code_information": [ { "code": "49505", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2601.27, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1926.87, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 9224.01, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 16737.11, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2601.27, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 16737.11, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Prq av fstl crtj uxtr 1 acs", "code_information": [ { "code": "36836", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 13235.9, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 9804.37, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 28170.25, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 51115.37, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 13235.9, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 51115.37, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Prq card angio/athrect 1 art", "code_information": [ { "code": "92924", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 8359.13, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 6191.95, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 24840.52, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 45073.55, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8359.13, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 45073.55, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Prq card revasc chronic 1vsl", "code_information": [ { "code": "92943", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 8359.13, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 6191.95, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 19459.31, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 35309.26, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8359.13, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 35309.26, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Prq card stent w/angio 1 vsl", "code_information": [ { "code": "92928", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 8359.13, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 6191.95, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 20060.31, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 36420.58, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8359.13, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 36420.58, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Prq card stent/ath/angio", "code_information": [ { "code": "92933", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 13235.9, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 9804.37, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 31419.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 57010.29, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 13235.9, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 57010.29, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Prq cardiac angioplast 1 art", "code_information": [ { "code": "92920", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4202.59, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3113.03, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 17830.42, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 32353.6, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4202.59, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 32353.6, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Prq revasc byp graft 1 vsl", "code_information": [ { "code": "92937", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 8359.13, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 6191.95, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 23984.84, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 43520.92, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8359.13, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 43520.92, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Prtl exc bone olecrn process", "code_information": [ { "code": "24147", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2391.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1771.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 17672.53, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 32067.18, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2391.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 32067.18, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PRUCALOPRIDE SUCCINATE 1 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "54092054601", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.29, "maximum": 37.65, "gross_charge": 40.05, "discounted_cash": 22.03, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.23, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.87, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.04, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.92, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.65, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.22, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.99, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.95, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.65, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.24, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.29, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.04, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.04, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.11, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.23, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.65, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.36, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.87, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.84, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.04, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.24, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.23, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.87, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PRUCALOPRIDE SUCCINATE 2 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "54092054701", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.29, "maximum": 37.65, "gross_charge": 40.05, "discounted_cash": 22.03, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.23, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.87, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.04, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.92, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.65, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.22, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.99, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.95, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.65, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.24, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.29, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.04, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.04, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.11, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.23, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.65, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.36, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.87, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.84, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.04, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.24, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.23, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.87, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Pseudoaneurysm injection trt", "code_information": [ { "code": "36002", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 455.72, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 337.57, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 758.88, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 1377.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 455.72, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 1377.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PSEUDOEPHEDRINE HCL 30 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00904699061", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PSEUDOEPHEDRINE HCL 60 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00904690706", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Pul art balloon repr percut", "code_information": [ { "code": "92997", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 8359.13, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 6191.95, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 30723.01, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 55747.47, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8359.13, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 55747.47, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Puncture aspir cyst breast", "code_information": [ { "code": "19000", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 518.62, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 384.16, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 3338.08, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 6057.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 518.62, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 6057.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Pvb thoracic single inj site", "code_information": [ { "code": "64461", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 510.46, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 378.12, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 2266.72, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 4113.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 510.46, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 4113.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PYRAZINAMIDE 100 MG/ML SUSPENSION", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "P6174801211", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.37, "maximum": 7.91, "gross_charge": 8.42, "discounted_cash": 4.63, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.88, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.6, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.74, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.13, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.45, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.04, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.04, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.04, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.91, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.41, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.37, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.16, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.32, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.97, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.73, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.91, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.59, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.6, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.69, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.32, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.41, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.88, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.6, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PYRAZINAMIDE 500 MG PO TABS", "drug_information": { "unit": "2.000000", "type": "UN" }, "code_information": [ { "code": "60687078911", "type": "NDC" } ], "standard_charges": [ { "minimum": 4.9, "maximum": 16.34, "gross_charge": 17.38, "discounted_cash": 9.56, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.08, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.49, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.9, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.72, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.06, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.34, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.41, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.34, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.29, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.9, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.77, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.04, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.12, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.82, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.34, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.61, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.49, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.82, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.04, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.29, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.08, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.49, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PYRIDOSTIGMINE BROMIDE 10 MG/2ML IV SOLN", "drug_information": { "unit": "2.000000", "type": "UN" }, "code_information": [ { "code": "00781304095", "type": "NDC" } ], "standard_charges": [ { "minimum": 19.21, "maximum": 1158.0, "gross_charge": 68.17, "discounted_cash": 37.49, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.54, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.17, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.84, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.72, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.83, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.77, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 64.08, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.99, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.21, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 57.94, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 51.13, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.02, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.36, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 64.08, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 53.38, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 51.13, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.99, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.54, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PYRIDOSTIGMINE BROMIDE 60 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68084049401", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PYRIDOSTIGMINE BROMIDE 60 MG/5ML PO SOLN", "drug_information": { "unit": "473.000000", "type": "UN" }, "code_information": [ { "code": "70954014810", "type": "NDC" } ], "standard_charges": [ { "minimum": 305.27, "maximum": 1018.28, "gross_charge": 1083.28, "discounted_cash": 595.8, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 628.3, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 591.47, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 866.62, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 917.54, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 315.23, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 519.97, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 648.88, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 647.8, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1018.28, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 953.29, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 305.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 920.79, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 812.46, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 381.64, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 736.63, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1018.28, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 848.21, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 591.47, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 861.21, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 812.46, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 953.29, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 628.3, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 591.47, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PYRIDOSTIGMINE BROMIDE ER 180 MG PO TBCR", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00187301330", "type": "NDC" } ], "standard_charges": [ { "minimum": 24.46, "maximum": 81.58, "gross_charge": 86.79, "discounted_cash": 47.73, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.34, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.39, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 69.43, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 73.51, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.26, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.66, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 51.99, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 51.9, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 81.58, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 76.38, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.46, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 73.77, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.09, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.58, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.02, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 81.58, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 67.96, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.39, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 69.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.09, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 76.38, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.34, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.39, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PYRIDOXINE HCL 10 MG/ML ORAL SUSPENSION", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "P0904052000", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PYRIDOXINE HCL 100 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "50268085915", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PYRIDOXINE HCL 100 MG/ML IJ SOLN", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "63323018001", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PYRIDOXINE HCL 25 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "R0536440601", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PYRIDOXINE HCL 50 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "77333094010", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PYRIMETHAMINE 25 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00480372056", "type": "NDC" } ], "standard_charges": [ { "minimum": 126.32, "maximum": 421.36, "gross_charge": 448.25, "discounted_cash": 246.54, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 259.99, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 244.74, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 358.6, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 379.67, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 130.44, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 215.16, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 268.5, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 268.05, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 421.36, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 394.46, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 126.32, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 381.01, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 336.19, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 157.92, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 304.81, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 421.36, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 350.98, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 244.74, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 356.36, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 336.19, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 394.46, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 259.99, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 244.74, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "PYRIMETHAMINE 5 MG/ML ORAL SUSPENSION", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "P5205433010", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 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"additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": 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total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "QUETIAPINE 10 MG/ML ORAL SUSPENSION", "drug_information": { "unit": "40.000000", "type": "UN" }, "code_information": [ { "code": "08252000157", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, 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"methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "QUETIAPINE FUMARATE 100 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687034901", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All 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}, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "QUETIAPINE FUMARATE 12.5 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "R6818044501", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "QUETIAPINE FUMARATE 200 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687036001", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "QUETIAPINE FUMARATE 25 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687032701", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", 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PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "QUETIAPINE FUMARATE 300 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "50268063415", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "QUETIAPINE FUMARATE 400 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00904664361", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "QUETIAPINE FUMARATE 50 MG PO TABS", "drug_information": { "unit": "2.000000", "type": "UN" }, "code_information": [ { "code": "00904663961", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "QUETIAPINE FUMARATE ER 200 MG PO TB24", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00310028260", "type": "NDC" } ], "standard_charges": [ { "minimum": 9.74, "maximum": 32.48, "gross_charge": 34.55, "discounted_cash": 19.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.04, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.86, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.64, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.26, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.05, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.58, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.7, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.66, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.48, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.4, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.74, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.37, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.91, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.17, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.49, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.48, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.05, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.86, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.47, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.91, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.4, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.04, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.86, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "QUETIAPINE FUMARATE ER 50 MG PO TB24", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00310028060", "type": "NDC" } ], "standard_charges": [ { "minimum": 5.21, "maximum": 17.39, "gross_charge": 18.5, "discounted_cash": 10.18, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.73, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.1, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.67, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.38, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.88, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.08, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.06, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.39, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.28, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.21, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.73, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.88, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.52, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.58, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.39, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.49, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.1, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.71, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.88, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.28, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.73, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.1, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "QUINIDINE GLUCONATE ER 324 MG PO TBCR", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "53489014101", "type": "NDC" } ], "standard_charges": [ { "minimum": 3.19, "maximum": 10.65, "gross_charge": 11.33, "discounted_cash": 6.23, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.57, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.19, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.06, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.6, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.3, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.44, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.79, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.65, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.97, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.19, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.63, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.99, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.7, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.65, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.87, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.19, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.01, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.97, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.57, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.19, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "R hrt art/grft angio", "code_information": [ { "code": "93457", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2370.82, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1756.16, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 13837.39, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 25108.17, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2370.82, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 25108.17, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "R hrt cath chd abnl nt cnj", "code_information": [ { "code": "93594", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2370.82, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1756.16, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 29987.32, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 54412.6, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2370.82, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 54412.6, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "R hrt cath chd nml nt cnj", "code_information": [ { "code": "93593", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2370.82, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1756.16, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 14167.72, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 25707.56, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2370.82, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 25707.56, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "R hrt coronary artery angio", "code_information": [ { "code": "93456", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2370.82, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1756.16, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 12915.69, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 23435.73, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2370.82, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 23435.73, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "R&l hrt art/ventricle angio", "code_information": [ { "code": "93460", "type": "HCPCS" }, { "code": "93461", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2370.82, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1756.16, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 13831.19, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 25096.93, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2370.82, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 25096.93, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "R&l hrt cath chd abnl nt cnj", "code_information": [ { "code": "93597", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2370.82, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1756.16, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 32059.86, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 58173.18, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2370.82, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 58173.18, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "R&l hrt cath chd nml nt cnj", "code_information": [ { "code": "93596", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2370.82, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1756.16, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 27567.2, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 50021.13, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2370.82, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 50021.13, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "R&l hrt cath w/ventriclgrphy", "code_information": [ { "code": "93453", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2370.82, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1756.16, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 17174.79, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 31163.95, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2370.82, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 31163.95, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Ra tracer id of sentinl node", "code_information": [ { "code": "38792", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 296.19, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 219.4, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 15621.47, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 28345.42, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 296.19, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 28345.42, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "RABIES IMMUNE GLOBULIN 1500 UNIT/5ML IJ SOLN", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "13533031805", "type": "NDC" } ], "standard_charges": [ { "minimum": 157.09, "maximum": 8807.71, "gross_charge": 9369.9, "discounted_cash": 5153.45, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5434.54, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 157.09, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7495.92, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7936.31, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2726.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4497.55, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5612.57, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 5603.2, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8807.71, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8245.51, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2640.44, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7964.42, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7027.43, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3301.02, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6371.53, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 8807.71, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7336.63, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 212.07, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7449.07, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7027.43, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8245.51, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5434.54, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 157.09, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "RABIES IMMUNE GLOBULIN 300 UNIT/ML IJ SOLN", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "13533031801", "type": "NDC" } ], "standard_charges": [ { "minimum": 157.09, "maximum": 2348.72, "gross_charge": 2498.64, "discounted_cash": 1374.25, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1449.21, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 157.09, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1998.91, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2116.35, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 727.1, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1199.35, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1496.69, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 1494.19, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2348.72, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2198.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 704.12, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2123.84, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1873.98, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 880.27, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1699.08, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2348.72, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1956.44, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 212.07, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1986.42, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1873.98, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2198.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1449.21, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 157.09, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "RABIES VACCINE PCEC IM SUSR", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "50632001001", "type": "NDC" } ], "standard_charges": [ { "minimum": 191.18, "maximum": 1158.53, "gross_charge": 1232.48, "discounted_cash": 677.86, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 714.84, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 191.18, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 985.98, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1043.91, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 358.65, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 591.59, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 738.26, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 737.02, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.53, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1084.58, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 347.31, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1047.61, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 924.36, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 434.2, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 838.09, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.53, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 965.03, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 258.09, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 979.82, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 924.36, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1084.58, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 714.84, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 191.18, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "RACEPINEPHRINE HCL 2.25 % IN NEBU", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00487590199", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Rad rescj tum tiss a/e 5 cm+", "code_information": [ { "code": "24079", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2109.62, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1562.68, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 7357.3, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 13349.93, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2109.62, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", 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"additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 19638.9, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2109.62, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 19638.9, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Rad resect hand tumor < 3 cm", "code_information": [ { "code": "26117", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2109.62, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": 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billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Rad resect hand tumor 3 cm/>", "code_information": [ { "code": "26118", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2109.62, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1562.68, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 8821.35, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 16572.28, "methodology": "percent of total 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"additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 29381.78, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 53551.93, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5265.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 53551.93, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "RADIUM RA 223 DICHLORIDE 30 MCCI/ML IV SOLN", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "50419020801", "type": "NDC" } ], "standard_charges": [ { "minimum": 161.85, "maximum": 539.89, "gross_charge": 574.35, "discounted_cash": 315.89, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 333.12, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 313.6, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 459.48, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 486.47, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 167.14, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 275.69, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 344.04, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 343.46, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 539.89, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 505.43, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 161.85, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 488.2, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 430.76, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 202.34, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 390.56, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 539.89, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 449.72, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 313.6, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 456.61, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 430.76, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 505.43, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 333.12, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 313.6, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "RALOXIFENE HCL 60 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687026621", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.63, "maximum": 8.78, "gross_charge": 9.34, "discounted_cash": 5.14, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.42, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.1, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.47, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.91, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.48, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.59, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.59, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.78, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.22, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.63, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.94, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.01, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.29, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.35, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.78, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.31, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.1, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.43, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.01, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.22, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.42, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.1, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "RALTEGRAVIR POTASSIUM 100 MG PO PACK", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "00006360361", "type": "NDC" } ], "standard_charges": [ { "minimum": 5.31, "maximum": 17.71, "gross_charge": 18.84, "discounted_cash": 10.36, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.93, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.29, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.07, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.96, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.48, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.04, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.29, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.71, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.58, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.31, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.01, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.13, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.64, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.81, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.71, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.75, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.29, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.98, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.13, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.58, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.93, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.29, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "RALTEGRAVIR POTASSIUM 400 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00006022761", "type": "NDC" } ], "standard_charges": [ { "minimum": 22.74, "maximum": 75.87, "gross_charge": 80.71, "discounted_cash": 44.39, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.81, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 44.07, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 64.57, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 68.36, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.49, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.74, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 48.35, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 48.26, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.87, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 71.02, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.74, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 68.6, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.53, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.43, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.88, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.87, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.2, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 44.07, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 64.16, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.53, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 71.02, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.81, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 44.07, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "RAMELTEON 8 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "64764080530", "type": "NDC" } ], "standard_charges": [ { "minimum": 8.27, "maximum": 27.6, "gross_charge": 29.36, "discounted_cash": 16.15, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.03, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.03, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.49, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.87, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.54, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.59, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.56, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.84, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.96, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.02, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.34, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.96, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.99, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.03, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.34, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.02, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.84, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.03, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.03, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "RAMIPRIL 1.25 MG PO CAPS", "drug_information": { "unit": "2.000000", "type": "UN" }, "code_information": [ { "code": "57237022230", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "RAMIPRIL 10 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "1672915501", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "RAMIPRIL 2.5 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "1672915301", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", 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"plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 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"standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "RAMIPRIL 5 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "R6800143000", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "RAMUCIRUMAB 100 MG/10ML IV SOLN", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "00002766901", "type": "NDC" } ], "standard_charges": [ { "minimum": 38.8, "maximum": 4108.15, "gross_charge": 4370.37, "discounted_cash": 2403.7, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2534.81, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.8, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3496.3, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3701.7, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1271.78, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2097.78, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2617.85, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2613.48, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4108.15, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3845.93, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1231.57, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3714.81, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3277.78, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1539.68, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2971.85, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4108.15, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3422.0, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.39, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3474.44, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3277.78, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3845.93, "standard_charge_percentage": 88.0, "methodology": 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"standard_charge_dollar": 7344.0, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 9164.7, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 9149.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14382.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13464.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 4311.54, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13005.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11475.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 5390.19, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 10404.0, 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"additional_payer_notes": "N/A", "standard_charge_dollar": 11475.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13464.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8874.0, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8353.8, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "RANIBIZUMAB 0.3 MG/0.05ML IZ SOSY", "drug_information": { "unit": "0.050000", "type": "UN" }, "code_information": [ { "code": "50242008203", "type": "NDC" } ], "standard_charges": [ { "minimum": 74.88, "maximum": 1648.99, "gross_charge": 1754.24, "discounted_cash": 964.83, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1017.46, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.88, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1403.39, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1485.84, "standard_charge_percentage": 85.0, "methodology": 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"standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1543.73, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 494.34, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1491.1, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1315.68, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 618.02, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1192.88, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1648.99, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1373.57, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 101.09, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1394.62, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1315.68, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1543.73, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1017.46, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.88, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "RANIBIZUMAB 0.5 MG/0.05ML IZ SOSY", "drug_information": { "unit": "0.050000", "type": "UN" }, "code_information": [ { "code": "50242008003", "type": "NDC" } ], "standard_charges": [ { "minimum": 74.88, "maximum": 2336.39, "gross_charge": 2485.52, "discounted_cash": 1367.04, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1441.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.88, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1988.42, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2105.24, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 723.29, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1193.05, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1488.83, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 1486.34, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2336.39, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2187.26, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 700.42, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2112.69, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1864.14, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 875.65, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1690.15, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2336.39, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1946.16, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 101.09, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1975.99, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1864.14, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2187.26, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1441.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.88, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "RANOLAZINE ER 1000 MG PO TB12", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "27241012602", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "RANOLAZINE ER 500 MG PO TB12", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687054921", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "RASAGILINE MESYLATE 0.5 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68546014256", "type": "NDC" } ], "standard_charges": [ { "minimum": 24.32, "maximum": 81.13, "gross_charge": 86.31, "discounted_cash": 47.47, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.06, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.13, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 69.05, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 73.1, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.12, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.43, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 51.7, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 51.61, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 81.13, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.95, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.32, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 73.36, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 64.73, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 58.69, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 81.13, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 67.58, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.13, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 68.62, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 64.73, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.95, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.06, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.13, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "RASAGILINE MESYLATE 1 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00093306156", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.32, "maximum": 4.4, "gross_charge": 4.68, "discounted_cash": 2.57, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.71, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.56, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.74, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.96, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.36, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.25, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.8, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.8, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.12, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.32, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.98, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.51, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.65, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.66, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.56, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.72, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.51, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.12, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.71, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.56, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "RASBURICASE 1.5 MG IV SOLR", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00024515010", "type": "NDC" } ], "standard_charges": [ { "minimum": 202.72, "maximum": 3030.14, "gross_charge": 3223.55, "discounted_cash": 1772.95, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1869.66, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 202.72, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2578.84, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2730.35, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 938.05, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1547.3, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1930.91, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 1927.68, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3030.14, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2836.72, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 908.4, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2740.02, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2417.66, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1135.66, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2192.01, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3030.14, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2524.04, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 273.68, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2562.72, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2417.66, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2836.72, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1869.66, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 202.72, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "RASBURICASE 7.5 MG IV SOLR", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "00024515175", "type": "NDC" } ], "standard_charges": [ { "minimum": 202.72, "maximum": 15150.65, "gross_charge": 16117.71, "discounted_cash": 8864.74, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 9348.27, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 202.72, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12894.17, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13651.7, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4690.25, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7736.5, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 9654.51, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 9638.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15150.65, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14183.58, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 4541.97, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13700.05, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12088.28, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 5678.27, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 10960.04, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 15150.65, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 12620.17, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 273.68, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 12813.58, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12088.28, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14183.58, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 9348.27, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 202.72, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "RAVULIZUMAB-CWVZ 300 MG/3ML IV SOLN", "drug_information": { "unit": "3.000000", "type": "UN" }, "code_information": [ { "code": "25682002501", "type": "NDC" } ], "standard_charges": [ { "minimum": 120.53, "maximum": 18059.28, "gross_charge": 19212.0, "discounted_cash": 10566.6, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 11142.96, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 120.53, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15369.6, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16272.56, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5590.69, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9221.76, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 11507.99, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 11394.0, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 18059.28, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16906.56, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 5413.94, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16330.2, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14409.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 6768.39, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 13064.16, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 18059.28, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 15043.0, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 162.71, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 15189.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14409.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16906.56, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 11142.96, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 120.53, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "Re-explore parathyroids", "code_information": [ { "code": "60502", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4360.43, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3229.95, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 14430.14, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 26183.71, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4360.43, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 26183.71, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Realignment of tendons", "code_information": [ { "code": "26437", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2391.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1771.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 8570.36, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 15551.1, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2391.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 15551.1, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Rebuild eardrum structures", "code_information": [ { "code": "69632", "type": "HCPCS" }, { "code": "69633", "type": "HCPCS" }, { "code": "69636", "type": "HCPCS" }, { "code": "69637", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4360.43, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3229.95, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 11938.29, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 21662.22, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4360.43, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 21662.22, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Rebuild outer ear canal", "code_information": [ { "code": "69310", "type": "HCPCS" }, { "code": "69320", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4360.43, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3229.95, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 11304.55, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 20512.3, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4360.43, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 20512.3, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Reconst lwr jaw w/fixation", "code_information": [ { "code": "21196", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4360.43, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3229.95, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 35909.12, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 65196.77, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4360.43, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 65196.77, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Reconst lwr jaw w/graft", "code_information": [ { "code": "21194", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4360.43, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3229.95, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 35357.85, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 64208.42, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4360.43, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 64208.42, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Reconst lwr jaw w/o fixation", "code_information": [ { "code": "21195", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4360.43, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3229.95, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 30749.37, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 55833.32, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4360.43, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 55833.32, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Reconst lwr jaw w/o graft", "code_information": [ { "code": "21193", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4360.43, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3229.95, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 44948.34, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 81559.51, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4360.43, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 81559.51, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Reconstr lwr jaw segment", "code_information": [ { "code": "21198", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4360.43, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3229.95, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 43132.98, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 78265.49, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4360.43, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 78265.49, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Reconstr lwr jaw w/advance", "code_information": [ { "code": "21199", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4360.43, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3229.95, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 19089.64, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 34638.46, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4360.43, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 34638.46, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Reconstruct ankle joint", "code_information": [ { "code": "27702", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 13555.31, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 10040.97, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 46924.28, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 85144.85, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 13555.31, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 85144.85, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Reconstruct cleft palate", "code_information": [ { "code": "42200", "type": "HCPCS" }, { "code": "42205", "type": "HCPCS" }, { "code": "42210", "type": "HCPCS" }, { "code": "42215", "type": "HCPCS" }, { "code": "42225", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4360.43, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3229.95, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1770.72, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 22535.24, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 40890.57, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4360.43, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2390.47, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 40890.57, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Reconstruct elbow joint", "code_information": [ { "code": "24361", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 13555.31, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 10040.97, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 41335.24, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 75003.48, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 13555.31, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 75003.48, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Reconstruct elbow lat ligmnt", "code_information": [ { "code": "24344", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 5265.64, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3900.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 33309.75, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 60496.21, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5265.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 60496.21, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Reconstruct elbow med ligmnt", "code_information": [ { "code": "24346", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 9484.13, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 7025.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 18754.09, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 34029.6, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 9484.13, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 34029.6, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Reconstruct entire forehead", "code_information": [ { "code": "21180", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 76488.23, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 138789.16, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 138789.16, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Reconstruct extra finger", "code_information": [ { "code": "26587", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2391.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1771.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 5148.98, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 9346.5, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2391.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 9346.5, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Reconstruct finger joint", "code_information": [ { "code": "26545", "type": "HCPCS" }, { "code": "26548", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2391.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1771.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 11461.67, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 20797.4, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2391.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 20797.4, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Reconstruct head of radius", "code_information": [ { "code": "24365", "type": "HCPCS" }, { "code": "24366", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 9484.13, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 7025.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 9502.62, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 17242.65, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 9484.13, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 17242.65, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Reconstruct lip with flap", "code_information": [ { "code": "40525", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2390.47, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1770.72, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 20198.04, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 36649.77, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2390.47, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 36649.77, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Reconstruct lower jaw bone", "code_information": [ { "code": "21255", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4360.43, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3229.95, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 20981.87, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 38071.93, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4360.43, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 38071.93, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Reconstruct orbit/forehead", "code_information": [ { "code": "21172", "type": "HCPCS" }, { "code": "21175", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4360.43, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3229.95, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 66576.81, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 120804.82, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4360.43, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 120804.82, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Reconstruct shoulder joint", "code_information": [ { "code": "23470", "type": "HCPCS" }, { "code": "23472", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 13555.31, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 7025.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 10040.97, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 45231.38, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 82073.15, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 9484.13, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 13555.31, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 82073.15, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Reconstruct ulna/radioulnar", "code_information": [ { "code": "25337", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 5265.64, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3900.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 12771.82, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 23174.67, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5265.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 23174.67, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Reconstruct upper jaw bone", "code_information": [ { "code": "21206", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4360.43, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3229.95, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 17831.02, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 32354.67, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4360.43, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 32354.67, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Reconstruct wrist joint", "code_information": [ { "code": "25441", "type": "HCPCS" }, { "code": "25445", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 9484.13, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 7025.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3900.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 32915.68, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 59726.06, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 9484.13, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5265.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 59726.06, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Reconstruction knee", "code_information": [ { "code": "27427", "type": "HCPCS" }, { "code": "27428", "type": "HCPCS" }, { "code": "27429", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 9484.13, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3900.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 7025.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 21152.49, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 38381.54, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5265.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 9484.13, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 38381.54, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Reconstruction of anus", "code_information": [ { "code": "46753", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2021.42, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1497.34, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 15429.64, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 27997.34, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2021.42, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 27997.34, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Reconstruction of bile ducts", "code_information": [ { "code": "47800", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 33086.56, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 60036.09, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 60036.09, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Reconstruction of chin", "code_information": [ { "code": "21120", "type": "HCPCS" }, { "code": "21121", "type": "HCPCS" }, { "code": "21122", "type": "HCPCS" }, { "code": "21123", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4360.43, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3229.95, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1770.72, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 27623.28, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 50122.87, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4360.43, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2390.47, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 50122.87, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Reconstruction of eyelid", "code_information": [ { "code": "67971", "type": "HCPCS" }, { "code": "67973", "type": "HCPCS" }, { "code": "67975", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1719.62, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1273.8, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 10751.95, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 19509.62, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1719.62, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 19509.62, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Reconstruction of hip socket", "code_information": [ { "code": "27120", "type": "HCPCS" }, { "code": "27122", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 29934.72, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 54317.03, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 54317.03, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Reconstruction of jaw", "code_information": [ { "code": "21245", "type": "HCPCS" }, { "code": "21248", "type": "HCPCS" }, { "code": "21249", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4360.43, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3229.95, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 15665.75, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 28425.75, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4360.43, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 28425.75, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Reconstruction of jaw joint", "code_information": [ { "code": "21240", "type": "HCPCS" }, { "code": "21243", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 13555.31, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3229.95, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 10040.97, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 22910.53, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 41571.51, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4360.43, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 13555.31, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 41571.51, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Reconstruction of lower jaw", "code_information": [ { "code": "21244", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4360.43, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3229.95, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 47299.54, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 85942.12, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4360.43, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 85942.12, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Reconstruction of mouth", "code_information": [ { "code": "40840", "type": "HCPCS" }, { "code": "40842", "type": "HCPCS" }, { "code": "40845", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4360.43, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3229.95, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 7046.37, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 12785.76, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4360.43, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 12785.76, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Reconstruction of nail bed", "code_information": [ { "code": "11762", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1348.33, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 998.76, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 8825.94, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 16014.81, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1348.33, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 16014.81, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Reconstruction of nose", "code_information": [ { "code": "30400", "type": "HCPCS" }, { "code": "30410", "type": "HCPCS" }, { "code": "30420", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4360.43, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3229.95, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 26431.88, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 48325.78, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4360.43, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 48325.78, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Reconstruction of orbit", "code_information": [ { "code": "21256", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4360.43, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3229.95, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 24806.24, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 45286.7, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4360.43, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 45286.7, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Reconstruction of throat", "code_information": [ { "code": "42950", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4360.43, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3229.95, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 14392.67, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 26129.72, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4360.43, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 26129.72, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Reconstruction of urethra", "code_information": [ { "code": "53410", "type": "HCPCS" }, { "code": "53430", "type": "HCPCS" }, { "code": "54308", "type": "HCPCS" }, { "code": "54316", "type": "HCPCS" }, { "code": "54322", "type": "HCPCS" }, { "code": "54324", "type": "HCPCS" }, { "code": "54326", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 6816.07, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2775.66, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5048.94, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1883.14, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 22860.65, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 41506.4, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3747.14, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6816.07, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2542.24, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 41506.4, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Reconstruction tongue fold", "code_information": [ { "code": "41520", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2390.47, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1770.72, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 3411.48, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 6190.2, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2390.47, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 6190.2, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Reduction of facial bones", "code_information": [ { "code": "21209", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4360.43, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3229.95, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 50457.3, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 91555.7, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4360.43, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 91555.7, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Reduction of forehead", "code_information": [ { "code": "21137", "type": "HCPCS" }, { "code": "21138", "type": "HCPCS" }, { "code": "21139", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4360.43, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1770.72, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3229.95, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 15181.75, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 27547.52, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2390.47, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4360.43, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 27547.52, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "REGADENOSON 0.4 MG/5ML IV SOLN", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "76329332100", "type": "NDC" } ], "standard_charges": [ { "minimum": 19.15, "maximum": 63.87, "gross_charge": 67.95, "discounted_cash": 37.37, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.41, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.1, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.36, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 57.55, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.77, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.62, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.7, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.63, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.87, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.15, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 57.76, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.96, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.94, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.21, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.87, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 53.2, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.1, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.02, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.96, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.41, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.1, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Reimplant ureter in bladder", "code_information": [ { "code": "50780", "type": "HCPCS" }, { "code": "50782", "type": "HCPCS" }, { "code": "50783", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 22013.69, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 39944.17, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 39944.17, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Reinforce eye wall", "code_information": [ { "code": "67250", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1719.62, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1273.8, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 4600.99, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 8348.56, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1719.62, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 8348.56, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Reinforce hip bones", "code_information": [ { "code": "27187", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 18113.86, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 32867.92, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 32867.92, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Reinforce humerus", "code_information": [ { "code": "24498", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 9484.13, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 7025.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 30249.51, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 54913.53, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 9484.13, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 54913.53, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Reinforce radius", "code_information": [ { "code": "25490", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 5265.64, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3900.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 16095.51, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 30097.46, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5265.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 30097.46, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Reinforce shoulder bones", "code_information": [ { "code": "23491", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 9484.13, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 7025.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 24163.09, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 43844.34, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 9484.13, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 43844.34, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Reinforce thigh", "code_information": [ { "code": "27495", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 18113.86, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 32867.92, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 32867.92, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Reinforce tibia", "code_information": [ { "code": "27745", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 5265.64, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3900.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 32882.32, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 59665.52, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5265.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 59665.52, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Reinforce/graft eye wall", "code_information": [ { "code": "67255", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2965.25, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2196.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 11180.15, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 20286.55, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2965.25, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 20286.55, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Reinnervate larynx", "code_information": [ { "code": "31590", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4360.43, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3229.95, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 31020.23, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 56409.48, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4360.43, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 56409.48, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Release eye tissue", "code_information": [ { "code": "67343", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1719.62, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1273.8, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 6401.26, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 11615.19, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1719.62, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 11615.19, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Release facial nerve", "code_information": [ { "code": "69725", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4360.43, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3229.95, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 31642.71, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 57945.05, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4360.43, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 57945.05, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Release finger contracture", "code_information": [ { "code": "26525", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1179.66, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 873.82, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 12841.74, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 23301.58, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1179.66, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 23301.58, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Release hand/finger tendon", "code_information": [ { "code": "26445", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2391.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1771.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 7405.26, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 13444.66, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2391.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 13444.66, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Release knuckle contracture", "code_information": [ { "code": "26520", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2391.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1771.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 8862.05, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 16080.32, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2391.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 16080.32, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Release muscles of hand", "code_information": [ { "code": "26593", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2391.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1771.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 11162.52, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 20254.58, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2391.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 20254.58, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Release of big toe", "code_information": [ { "code": "28240", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2391.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1771.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 9016.41, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 16360.42, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2391.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 16360.42, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Release of eye fluid", "code_information": [ { "code": "67015", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1681.13, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1245.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 10229.07, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 18560.81, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1681.13, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 18560.81, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Release of foot contracture", "code_information": [ { "code": "28270", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2391.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1771.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 11034.83, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 20022.88, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2391.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 20022.88, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Release of toe joint each", "code_information": [ { "code": "28272", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1179.66, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 873.82, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 28386.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 51506.9, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1179.66, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 51506.9, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Release of ureter", "code_information": [ { "code": "50715", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 46953.6, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 85198.07, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 85198.07, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Release palm & finger tendon", "code_information": [ { "code": "26442", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2391.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1771.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 12841.74, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 23301.58, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2391.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 23301.58, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Release palm contracture", "code_information": [ { "code": "26040", "type": "HCPCS" }, { "code": "26045", "type": "HCPCS" }, { "code": "26121", "type": "HCPCS" }, { "code": "26123", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2391.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 873.82, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1771.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 7133.6, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 12944.06, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1179.66, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2391.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 12944.06, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Release palm/finger tendon", "code_information": [ { "code": "26440", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1179.66, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 873.82, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 11162.52, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 20254.58, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1179.66, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 20254.58, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Release shoulder joint", "code_information": [ { "code": "23020", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2391.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1771.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 16508.32, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 29954.66, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2391.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 29954.66, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Release spinal cord lumbar", "code_information": [ { "code": "63200", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 12950.08, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 23498.12, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 23498.12, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Release wrist/forearm tendon", "code_information": [ { "code": "25295", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2391.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1771.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 10562.32, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 19165.5, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2391.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 19165.5, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Relieve bladder contracture", "code_information": [ { "code": "52640", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2542.24, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1883.14, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 12074.2, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 21908.82, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2542.24, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 21908.82, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Relieve inner eye pressure", "code_information": [ { "code": "65820", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2965.25, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2196.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 5112.86, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 9277.38, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2965.25, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 9277.38, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Relieve pressure on nerve(s)", "code_information": [ { "code": "64722", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1439.39, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1066.21, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 6696.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 12160.8, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1439.39, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 12160.8, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Relocation pocket pacemaker", "code_information": [ { "code": "33222", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1348.33, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 998.76, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 21013.21, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 38128.82, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1348.33, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 38128.82, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Rem endovas vena cava filter", "code_information": [ { "code": "37193", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2320.02, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1718.54, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 11284.34, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 20475.64, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2320.02, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 20475.64, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "REMDESIVIR 100 MG IV SOLR", "drug_information": { "unit": "20.000000", "type": "UN" }, "code_information": [ { "code": "61958290102", "type": "NDC" } ], "standard_charges": [ { "minimum": 675.73, "maximum": 2254.04, "gross_charge": 2397.92, "discounted_cash": 1318.86, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1390.79, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1309.26, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1918.34, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2031.04, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 697.79, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1151.0, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1436.35, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 1433.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2254.04, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2110.17, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 675.73, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2038.23, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1798.44, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 844.79, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1630.59, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2254.04, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1877.57, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1309.26, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1906.35, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1798.44, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2110.17, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1390.79, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1309.26, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "REMIFENTANIL HCL 2 MG IV SOLR", "drug_information": { "unit": "2.000000", "type": "ME" }, "code_information": [ { "code": "00143939210", "type": "NDC" } ], "standard_charges": [ { "minimum": 102.24, "maximum": 1158.0, "gross_charge": 362.8, "discounted_cash": 199.54, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 210.42, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 198.09, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 314.91, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 105.57, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 174.14, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 217.32, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 216.95, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 341.03, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 319.26, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 102.24, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 308.38, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 272.1, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 127.81, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 246.7, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 341.03, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 284.07, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 198.09, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 288.43, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 272.1, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 319.26, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 210.42, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 198.09, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "REMIFENTANIL HCL 5 MG IV SOLR", "drug_information": { "unit": "5.000000", "type": "ME" }, "code_information": [ { "code": "67457019810", "type": "NDC" } ], "standard_charges": [ { "minimum": 66.91, "maximum": 1158.0, "gross_charge": 237.44, "discounted_cash": 130.59, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 137.72, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 129.64, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 206.1, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 69.1, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 113.97, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 142.23, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 141.99, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 223.19, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 208.95, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 66.91, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 201.82, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 178.08, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 83.65, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 161.46, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 223.19, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 185.92, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 129.64, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 188.76, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 178.08, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 208.95, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 137.72, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 129.64, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "REMIMAZOLAM BESYLATE 20 MG IV SOLR", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "71390001111", "type": "NDC" } ], "standard_charges": [ { "minimum": 25.85, "maximum": 86.23, "gross_charge": 91.73, "discounted_cash": 50.45, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 53.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.08, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 73.38, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 77.7, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.69, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 44.03, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.95, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.85, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.23, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 80.72, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.85, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 77.97, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 68.8, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.32, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 62.38, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.23, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 71.82, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.08, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 72.93, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 68.8, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 80.72, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 53.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.08, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Removal biliary drg cath", "code_information": [ { "code": "47537", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 691.08, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 511.91, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 9116.15, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 16541.41, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 691.08, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 16541.41, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Removal foreign body jawbone", "code_information": [ { "code": "41806", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1091.85, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 808.78, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 11863.98, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 21527.38, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1091.85, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 21527.38, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Removal implant superficial", "code_information": [ { "code": "20670", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1194.28, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 884.65, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 8565.92, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 15543.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1194.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 15543.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Removal of adenoids", "code_information": [ { "code": "42830", "type": "HCPCS" }, { "code": "42831", "type": "HCPCS" }, { "code": "42835", "type": "HCPCS" }, { "code": "42836", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2390.47, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1770.72, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 5963.18, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 10820.3, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2390.47, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 10820.3, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Removal of anal fissure", "code_information": [ { "code": "46200", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2021.42, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1497.34, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 4847.9, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 8796.6, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2021.42, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 8796.6, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Removal of anal tags", "code_information": [ { "code": "46230", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2021.42, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1497.34, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 4883.12, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 8860.5, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2021.42, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 8860.5, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Removal of ankle/heel lesion", "code_information": [ { "code": "28100", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2391.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1771.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 17433.38, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 31633.16, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2391.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 31633.16, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Removal of bladder cyst", "code_information": [ { "code": "51500", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4300.51, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3185.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 7574.4, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 13743.87, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4300.51, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 13743.87, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Removal of bladder lesion", "code_information": [ { "code": "51530", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 18520.75, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 33606.18, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 33606.18, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Removal of bladder stone", "code_information": [ { "code": "51050", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 3747.14, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2775.66, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 14315.41, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 25975.55, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3747.14, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 25975.55, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Removal of bone for graft", "code_information": [ { "code": "20900", "type": "HCPCS" }, { "code": "20902", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 5265.64, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3900.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 18908.96, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 34310.62, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5265.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 34310.62, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Removal of bone lesion", "code_information": [ { "code": "23140", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2391.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1771.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 6514.11, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 11819.95, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2391.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 11819.95, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Removal of breast lesion", "code_information": [ { "code": "19120", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2822.56, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2090.79, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 7143.39, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 12961.8, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2822.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 12961.8, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Removal of breast tissue", "code_information": [ { "code": "19300", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2822.56, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2090.79, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 11674.35, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 21462.3, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2822.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 21462.3, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Removal of cervix", "code_information": [ { "code": "57530", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 3638.66, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2695.3, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 42674.53, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 77433.65, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3638.66, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 77433.65, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Removal of collar bone", "code_information": [ { "code": "23125", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2391.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1771.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 17731.04, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 35304.99, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2391.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 35304.99, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Removal of epididymis", "code_information": [ { "code": "54860", "type": "HCPCS" }, { "code": "54861", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2542.24, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1883.14, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 8429.52, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 15295.5, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2542.24, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 15295.5, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Removal of epiglottis", "code_information": [ { "code": "31420", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4360.43, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3229.95, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 18054.71, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 32760.6, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4360.43, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 32760.6, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Removal of esophagus pouch", "code_information": [ { "code": "43130", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4360.43, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3229.95, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 13854.4, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 25139.05, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4360.43, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 25139.05, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Removal of ethmoid sinus", "code_information": [ { "code": "31200", "type": "HCPCS" }, { "code": "31201", "type": "HCPCS" }, { "code": "31205", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4360.43, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3229.95, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 808.78, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1770.72, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 14601.11, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 26493.97, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4360.43, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1091.85, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2390.47, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 26493.97, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Removal of external ear", "code_information": [ { "code": "69120", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4360.43, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3229.95, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 43791.98, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 79461.28, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4360.43, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 79461.28, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Removal of eye", "code_information": [ { "code": "65101", "type": "HCPCS" }, { "code": "65110", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2779.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2058.97, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 13519.82, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 24531.95, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2779.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 24531.95, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Removal of eye lesion", "code_information": [ { "code": "65400", "type": "HCPCS" }, { "code": "65420", "type": "HCPCS" }, { "code": "65426", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1719.62, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 528.82, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1273.8, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 5414.82, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 9825.26, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 713.91, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1719.62, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 9825.26, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Removal of face wrinkles", "code_information": [ { "code": "15828", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2698.5, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1998.89, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 48706.19, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 88525.77, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2698.5, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 88525.77, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Removal of fallopian tube", "code_information": [ { "code": "58700", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 25390.63, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 46071.72, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 46071.72, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Removal of fascia for graft", "code_information": [ { "code": "20920", "type": "HCPCS" }, { "code": "20922", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1348.33, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 998.76, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 15309.4, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 27779.19, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1348.33, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 27779.19, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Removal of finger lesion", "code_information": [ { "code": "26210", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1179.66, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 873.82, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 4017.1, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 7289.1, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1179.66, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 7289.1, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Removal of finger tendon", "code_information": [ { "code": "26180", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1179.66, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 873.82, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 8919.03, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 16183.74, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1179.66, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 16183.74, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Removal of foot foreign body", "code_information": [ { "code": "28190", "type": "HCPCS" }, { "code": "28192", "type": "HCPCS" }, { "code": "28193", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1194.28, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 384.16, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 884.65, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 5336.96, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 9684.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 518.62, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1194.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 9684.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Removal of foot lesion", "code_information": [ { "code": "28080", "type": "HCPCS" }, { "code": "28090", "type": "HCPCS" }, { "code": "28104", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2391.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 873.82, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1771.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 5324.56, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 9661.5, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1179.66, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2391.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 9661.5, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Removal of forearm lesion", "code_information": [ { "code": "25120", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2391.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1771.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 14876.54, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 27203.08, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2391.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 27203.08, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Removal of forehead wrinkles", "code_information": [ { "code": "15824", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1348.33, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 998.76, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 59190.99, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 107758.67, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1348.33, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 107758.67, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Removal of foreign body", "code_information": [ { "code": "20520", "type": "HCPCS" }, { "code": "20525", "type": "HCPCS" }, { "code": "27372", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2109.62, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 884.65, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1562.68, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 5211.46, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 9456.3, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1194.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2109.62, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 9456.3, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Removal of gallbladder", "code_information": [ { "code": "47600", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 33086.56, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 60036.09, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 60036.09, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Removal of heel bone", "code_information": [ { "code": "28118", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2391.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1771.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 18172.49, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 32974.27, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2391.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 32974.27, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Removal of heel spur", "code_information": [ { "code": "28119", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2391.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1771.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 7266.55, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 13185.26, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2391.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 13185.26, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Removal of humerus lesion", "code_information": [ { "code": "23150", "type": "HCPCS" }, { "code": "23155", "type": "HCPCS" }, { "code": "23156", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 5265.64, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1771.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3900.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 10045.86, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 18507.4, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2391.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5265.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 18507.4, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Removal of hydrocele", "code_information": [ { "code": "55040", "type": "HCPCS" }, { "code": "55500", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2601.27, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1926.87, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1883.14, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 8291.75, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 15045.51, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2601.27, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2542.24, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 15045.51, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Removal of hydroceles", "code_information": [ { "code": "55041", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2601.27, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1926.87, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 8152.89, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 14793.55, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2601.27, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 14793.55, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Removal of implant deep", "code_information": [ { "code": "20680", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2109.62, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1562.68, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 12328.58, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 22370.4, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2109.62, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 22370.4, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Removal of implant from hand", "code_information": [ { "code": "26320", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1194.28, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 884.65, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 14886.92, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 27012.56, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1194.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 27012.56, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Removal of inner eye fluid", "code_information": [ { "code": "67036", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2965.25, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2196.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 8248.25, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 14966.59, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2965.25, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 14966.59, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Removal of inner eye lesion", "code_information": [ { "code": "66770", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 404.37, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 299.54, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 6474.54, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 11958.37, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 404.37, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 11958.37, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Removal of intranasal lesion", "code_information": [ { "code": "30117", "type": "HCPCS" }, { "code": "30118", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2390.47, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1770.72, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 19984.16, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 36261.59, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2390.47, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 36261.59, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Removal of iris", "code_information": [ { "code": "66625", "type": "HCPCS" }, { "code": "66630", "type": "HCPCS" }, { "code": "66635", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1681.13, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1245.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 6749.12, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 12246.38, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1681.13, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 12246.38, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Removal of ischial bursa", "code_information": [ { "code": "27060", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 5265.64, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3900.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 18150.42, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 32934.22, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5265.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 32934.22, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Removal of jaw joint", "code_information": [ { "code": "21050", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4360.43, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3229.95, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 42950.62, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 77934.64, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4360.43, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 77934.64, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Removal of knee cyst", "code_information": [ { "code": "27345", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2391.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1771.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 15890.55, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 29587.24, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2391.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 29587.24, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Removal of kneecap", "code_information": [ { "code": "27350", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 5265.64, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3900.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 21493.72, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 39000.7, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5265.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 39000.7, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Removal of kneecap bursa", "code_information": [ { "code": "27340", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2391.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1771.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 7077.56, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 12842.35, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2391.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 12842.35, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Removal of leg artery clot", "code_information": [ { "code": "34203", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 3984.54, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2951.51, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 34678.49, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 63147.9, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3984.54, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 63147.9, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Removal of lens lesion", "code_information": [ { "code": "66830", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1681.13, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1245.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 11148.11, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 20228.42, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1681.13, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 20228.42, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Removal of lens material", "code_information": [ { "code": "66840", "type": "HCPCS" }, { "code": "66850", "type": "HCPCS" }, { "code": "66852", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2965.25, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1245.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2196.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 7872.92, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 14496.36, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1681.13, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2965.25, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 14496.36, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Removal of lymph nodes neck", "code_information": [ { "code": "38700", "type": "HCPCS" }, { "code": "38720", "type": "HCPCS" }, { "code": "38724", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4806.97, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3560.72, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 16725.41, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 30348.55, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4806.97, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 30348.55, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Removal of neck wrinkles", "code_information": [ { "code": "15825", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2698.5, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1998.89, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 26986.47, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 48967.39, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2698.5, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 48967.39, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Removal of nerve lesion", "code_information": [ { "code": "64790", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1439.39, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1066.21, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 10126.44, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 18374.59, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1439.39, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 18374.59, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Removal of nose", "code_information": [ { "code": "30160", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4360.43, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3229.95, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 38047.24, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 69037.35, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4360.43, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 69037.35, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Removal of nose lesion", "code_information": [ { "code": "30124", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1091.85, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 808.78, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 8126.96, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 14757.51, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1091.85, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 14757.51, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Removal of nose polyp(s)", "code_information": [ { "code": "30110", "type": "HCPCS" }, { "code": "30115", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2390.47, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 808.78, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1770.72, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 25023.49, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 45847.47, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1091.85, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2390.47, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 45847.47, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Removal of ocular implant", "code_information": [ { "code": "65175", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2779.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2058.97, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 8026.55, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 14564.32, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2779.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 14564.32, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Removal of ovarian cyst(s)", "code_information": [ { "code": "58925", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 3638.66, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2695.3, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 15320.4, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 27799.12, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3638.66, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 27799.12, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Removal of ovary/tube(s)", "code_information": [ { "code": "58720", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 17465.16, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 36149.23, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 36149.23, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Removal of pacemaker system", "code_information": [ { "code": "33234", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2682.53, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1987.06, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 19948.86, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 36197.54, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2682.53, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 36197.54, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Removal of palm tendon each", "code_information": [ { "code": "26170", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1179.66, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 873.82, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 5283.38, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 9586.8, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1179.66, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 9586.8, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Removal of penis", "code_information": [ { "code": "54125", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 32426.67, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 58838.75, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 58838.75, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Removal of pm generator", "code_information": [ { "code": "33233", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 6100.22, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4518.69, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 32797.57, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 59511.74, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6100.22, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 59511.74, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Removal of rectal marker", "code_information": [ { "code": "46030", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 869.1, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 643.78, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 4339.97, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 7875.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 869.1, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 7875.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Removal of rib", "code_information": [ { "code": "21615", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 26146.51, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 47443.28, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 47443.28, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Removal of rib and nerves", "code_information": [ { "code": "21616", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 20087.47, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 36449.05, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 36449.05, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Removal of salivary stone", "code_information": [ { "code": "42330", "type": "HCPCS" }, { "code": "42335", "type": "HCPCS" }, { "code": "42340", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2390.47, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1770.72, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 12699.12, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 23042.74, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2390.47, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 23042.74, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Removal of scrotum", "code_information": [ { "code": "55150", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2542.24, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1883.14, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 8697.36, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 15781.5, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2542.24, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 15781.5, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Removal of scrotum lesion", "code_information": [ { "code": "55120", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1509.96, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1118.49, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 33143.19, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 60138.86, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1509.96, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 60138.86, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Removal of sesamoid bone", "code_information": [ { "code": "28315", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2391.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1771.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 8592.85, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 15591.85, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2391.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 15591.85, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Removal of shunt", "code_information": [ { "code": "49429", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2320.02, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1718.54, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 12103.18, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 21961.42, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2320.02, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 21961.42, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Removal of skin wrinkles", "code_information": [ { "code": "15829", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2698.5, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1998.89, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 38285.86, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 69530.23, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2698.5, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 69530.23, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Removal of skull lesion", "code_information": [ { "code": "61500", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 31590.93, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 57322.26, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 57322.26, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Removal of sperm cord lesion", "code_information": [ { "code": "55520", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2542.24, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1883.14, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 9595.75, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 17915.64, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2542.24, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 17915.64, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Removal of sperm duct(s)", "code_information": [ { "code": "55250", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1509.96, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1118.49, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 6839.93, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 13159.94, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1509.96, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 13159.94, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Removal of tail bone", "code_information": [ { "code": "27080", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2391.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1771.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 14249.05, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 25855.13, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2391.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 25855.13, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Removal of tear sac", "code_information": [ { "code": "68520", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2779.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2058.97, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 10350.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 18780.26, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2779.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 18780.26, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Removal of tendon for graft", "code_information": [ { "code": "20924", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 5265.64, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3900.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 10101.02, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 18965.97, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5265.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 18965.97, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Removal of tendon lesion", "code_information": [ { "code": "27630", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2391.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1771.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 10667.97, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 19357.2, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2391.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 19357.2, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Removal of testis", "code_information": [ { "code": "54520", "type": "HCPCS" }, { "code": "54530", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2601.27, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1883.14, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1926.87, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 7015.92, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 12730.5, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2542.24, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2601.27, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 12730.5, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Removal of thymus gland", "code_information": [ { "code": "60520", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4360.43, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3229.95, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 18458.6, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 33493.43, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4360.43, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 33493.43, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Removal of thyroid", "code_information": [ { "code": "60240", "type": "HCPCS" }, { "code": "60252", "type": "HCPCS" }, { "code": "60271", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4360.43, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3185.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3229.95, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 18462.81, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 33501.1, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4300.51, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4360.43, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 33501.1, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Removal of toe lesions", "code_information": [ { "code": "28092", "type": "HCPCS" }, { "code": "28108", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1179.66, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 873.82, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 5624.63, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 10476.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1179.66, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 10476.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Removal of tonsils", "code_information": [ { "code": "42825", "type": "HCPCS" }, { "code": "42826", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4360.43, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3229.95, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1770.72, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 7805.96, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 14164.03, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4360.43, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2390.47, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 14164.03, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Removal of upper jaw", "code_information": [ { "code": "31225", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 23437.21, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 42727.03, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 42727.03, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Removal of urethra", "code_information": [ { "code": "53215", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 3747.14, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2775.66, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 5409.99, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 9816.51, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3747.14, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 9816.51, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Removal of urethra gland", "code_information": [ { "code": "53270", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2542.24, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1883.14, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 9577.26, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 17378.1, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2542.24, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 17378.1, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Removal of urethra lesion", "code_information": [ { "code": "53230", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 3747.14, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2775.66, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 13749.8, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 24949.22, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3747.14, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 24949.22, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Removal of wrist bone", "code_information": [ { "code": "25210", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2391.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1771.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 6797.68, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 12686.4, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2391.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 12686.4, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Removal of wrist bones", "code_information": [ { "code": "25215", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2391.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1771.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 25746.68, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 46717.78, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2391.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 46717.78, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Removal of wrist lesion", "code_information": [ { "code": "25130", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2391.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1771.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 8594.44, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 16241.85, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2391.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 16241.85, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Removal pacemaker electrode", "code_information": [ { "code": "33235", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2682.53, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1987.06, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 47310.52, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 85845.74, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2682.53, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 85845.74, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Removal prosth radial head", "code_information": [ { "code": "24164", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2391.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1771.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 9882.8, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 17932.5, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2391.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 17932.5, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Removal sutr/staple req anes", "code_information": [ { "code": "15851", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1348.33, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 998.76, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 6159.65, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 11176.78, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1348.33, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 11176.78, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Remove & graft wrist lesion", "code_information": [ { "code": "25135", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 5265.64, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3900.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 12123.78, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 21998.79, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5265.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 21998.79, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Remove anal fist complex", "code_information": [ { "code": "46280", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2021.42, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1497.34, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 6088.4, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 11317.5, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2021.42, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 11317.5, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Remove anal fist inter", "code_information": [ { "code": "46275", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2021.42, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1497.34, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 6620.4, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 12282.84, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2021.42, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 12282.84, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Remove anal fist subq", "code_information": [ { "code": "46270", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2021.42, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1497.34, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 5795.25, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 10515.6, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2021.42, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 10515.6, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Remove ankle joint lining", "code_information": [ { "code": "27626", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2391.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1771.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 18669.23, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 33875.61, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2391.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 33875.61, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Remove armpit lymph nodes", "code_information": [ { "code": "38740", "type": "HCPCS" }, { "code": "38745", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4300.51, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3185.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 12176.68, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 22094.78, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4300.51, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 22094.78, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Remove bladder stone", "code_information": [ { "code": "52317", "type": "HCPCS" }, { "code": "52318", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2542.24, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1883.14, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 12303.21, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 22324.38, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2542.24, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 22324.38, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Remove blood clot from eye", "code_information": [ { "code": "65930", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1681.13, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1245.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 7778.27, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 14113.8, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1681.13, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 14113.8, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Remove brain cavity shunt", "code_information": [ { "code": "62256", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 11388.24, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 20664.16, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 20664.16, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Remove carotid body lesion", "code_information": [ { "code": "60600", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 21232.55, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 38526.79, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 38526.79, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Remove cartilage for graft", "code_information": [ { "code": "20910", "type": "HCPCS" }, { "code": "20912", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2698.5, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 334.22, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1998.89, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 21948.52, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 39859.86, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 451.2, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2698.5, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 39859.86, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Remove cerclage suture", "code_information": [ { "code": "59871", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2343.63, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1736.02, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 4189.22, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 7601.4, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2343.63, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 7601.4, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Remove contraceptive capsule", "code_information": [ { "code": "11976", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 518.62, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 1817.86, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 3298.53, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 518.62, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 3298.53, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Remove coronoid process", "code_information": [ { "code": "21070", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4360.43, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3229.95, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 22224.21, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 40326.18, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4360.43, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 40326.18, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Remove digit nerve lesion", "code_information": [ { "code": "64776", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1439.39, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1066.21, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 16334.43, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 29925.82, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1439.39, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 29925.82, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Remove drug implant device", "code_information": [ { "code": "11982", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 294.13, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 1373.92, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 2493.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 294.13, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 2493.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Remove ear canal lesion(s)", "code_information": [ { "code": "69140", "type": "HCPCS" }, { "code": "69145", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4360.43, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3229.95, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1562.68, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 14732.57, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 26732.47, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4360.43, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2109.62, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 26732.47, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Remove ear lesion", "code_information": [ { "code": "69550", "type": "HCPCS" }, { "code": "69552", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4360.43, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3229.95, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 14196.15, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 28405.3, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4360.43, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 28405.3, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Remove elctrd transvenously", "code_information": [ { "code": "33244", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2682.53, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1987.06, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 15789.95, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 28651.11, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2682.53, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 28651.11, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Remove epididymis lesion", "code_information": [ { "code": "54830", "type": "HCPCS" }, { "code": "54840", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2542.24, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1883.14, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1118.49, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 8756.88, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 15889.5, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2542.24, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1509.96, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 15889.5, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Remove exostosis mandible", "code_information": [ { "code": "21031", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2390.47, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1770.72, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 8337.76, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 15129.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2390.47, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 15129.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Remove exostosis maxilla", "code_information": [ { "code": "21032", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2390.47, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1770.72, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 13004.95, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 23597.69, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2390.47, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 23597.69, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Remove ext hem groups 2+", "code_information": [ { "code": "46250", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2021.42, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1497.34, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 4519.67, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 8201.01, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2021.42, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 8201.01, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Remove external ear partial", "code_information": [ { "code": "69110", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2109.62, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1562.68, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 9058.94, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 16437.6, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2109.62, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 16437.6, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Remove eye implant material", "code_information": [ { "code": "67120", "type": "HCPCS" }, { "code": "67121", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1681.13, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1245.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 5978.77, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 10848.56, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1681.13, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 10848.56, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Remove eye lesion", "code_information": [ { "code": "65900", "type": "HCPCS" }, { "code": "66130", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1719.62, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1245.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1273.8, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 5997.79, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 10883.07, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1681.13, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1719.62, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 10883.07, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Remove eye/attach implant", "code_information": [ { "code": "65105", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2779.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2058.97, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 9623.26, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 17461.57, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2779.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 17461.57, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Remove eye/insert implant", "code_information": [ { "code": "65103", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2779.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2058.97, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 10453.71, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 18968.45, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2779.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 18968.45, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Remove eyelid foreign body", "code_information": [ { "code": "67938", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 220.34, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 163.22, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 7058.08, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 12807.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 220.34, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 12807.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Remove eyelid lesion", "code_information": [ { "code": "67800", "type": "HCPCS" }, { "code": "67840", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 713.91, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 163.22, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 528.82, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 2046.32, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 3713.09, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 220.34, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 713.91, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 3713.09, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Remove eyelid lesion(s)", "code_information": [ { "code": "67808", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1719.62, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1273.8, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 4578.61, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 8307.95, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1719.62, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 8307.95, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Remove eyelid lesions", "code_information": [ { "code": "67801", "type": "HCPCS" }, { "code": "67805", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 713.91, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 528.82, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 163.22, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 6573.57, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 11927.83, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 713.91, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 220.34, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 11927.83, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Remove eyelid lining lesion", "code_information": [ { "code": "68110", "type": "HCPCS" }, { "code": "68115", "type": "HCPCS" }, { "code": "68130", "type": "HCPCS" }, { "code": "68135", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1719.62, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1273.8, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 7421.31, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 13466.1, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1719.62, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 13466.1, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Remove femur lesion", "code_information": [ { "code": "27355", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2391.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1771.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 9473.18, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 17189.24, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2391.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 17189.24, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Remove femur lesion/bursa", "code_information": [ { "code": "27062", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2391.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1771.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 13420.23, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 24351.22, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2391.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 24351.22, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Remove femur lesion/graft", "code_information": [ { "code": "27356", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 9484.13, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 7025.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 11752.98, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 21325.98, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 9484.13, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 21325.98, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Remove finger bone", "code_information": [ { "code": "26185", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1179.66, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 873.82, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 4841.46, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 8784.9, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1179.66, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 8784.9, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Remove foreign body adbomen", "code_information": [ { "code": "49402", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2601.27, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1926.87, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 18652.95, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 34994.51, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2601.27, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 34994.51, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Remove foreign body brain", "code_information": [ { "code": "61570", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 24526.96, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 44740.72, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 44740.72, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Remove foreign body from eye", "code_information": [ { "code": "65235", "type": "HCPCS" }, { "code": "65260", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1681.13, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1245.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 4402.62, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 7988.63, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1681.13, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 7988.63, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Remove groin lymph nodes", "code_information": [ { "code": "38760", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4806.97, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3560.72, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 6464.57, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 11730.06, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4806.97, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 11730.06, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Remove hand bone lesion", "code_information": [ { "code": "26200", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1179.66, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 873.82, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 10824.37, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 19640.97, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1179.66, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 19640.97, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Remove hip bone les deep", "code_information": [ { "code": "27066", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2391.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1771.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 16542.61, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 30016.82, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2391.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 30016.82, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Remove hip bone les super", "code_information": [ { "code": "27065", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 5265.64, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3900.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 23393.8, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 42448.46, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5265.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 42448.46, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Remove implant of eye", "code_information": [ { "code": "65920", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1681.13, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1245.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 15419.04, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 27978.07, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1681.13, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 27978.07, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Remove in/ex hem groups 2+", "code_information": [ { "code": "46260", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2021.42, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1497.34, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 6659.57, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 12083.89, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2021.42, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 12083.89, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Remove in/ex hem grp & fiss", "code_information": [ { "code": "46257", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2021.42, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1497.34, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 6052.68, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 10982.7, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2021.42, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 10982.7, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Remove in/ex hem grp w/fistu", "code_information": [ { "code": "46258", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2021.42, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1497.34, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 6361.2, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 11542.5, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2021.42, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 11542.5, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Remove in/ex hem grps & fiss", "code_information": [ { "code": "46261", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2021.42, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1497.34, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 5734.7, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 10405.71, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2021.42, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 10405.71, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Remove inner ear & mastoid", "code_information": [ { "code": "69910", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4360.43, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3229.95, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 18877.3, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 34253.16, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4360.43, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 34253.16, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Remove int/ext hem 1 group", "code_information": [ { "code": "46255", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2021.42, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1497.34, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 7502.99, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 13614.3, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2021.42, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 13614.3, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Remove intrvas foreign body", "code_information": [ { "code": "37197", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2320.02, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1718.54, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 39529.52, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 71727.02, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2320.02, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 71727.02, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Remove iris and lesion", "code_information": [ { "code": "66600", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2965.25, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2196.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 17761.75, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 32228.98, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2965.25, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 32228.98, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Remove knee cyst", "code_information": [ { "code": "27347", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2391.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1771.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 11116.8, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 20685.59, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2391.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 20685.59, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Remove knee joint lining", "code_information": [ { "code": "27334", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2391.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1771.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 14799.73, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 26854.35, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2391.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 26854.35, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Remove lamina/facets lumbar", "code_information": [ { "code": "63012", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 5265.64, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3900.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 61569.33, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 111718.58, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5265.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 111718.58, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Remove limb nerve lesion", "code_information": [ { "code": "64782", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1439.39, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1066.21, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 5813.69, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 10549.05, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1439.39, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 10549.05, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Remove lower leg bone lesion", "code_information": [ { "code": "27635", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2391.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1771.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 9601.08, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 17421.3, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2391.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 17421.3, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Remove lung catheter", "code_information": [ { "code": "32552", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 455.72, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 337.57, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 2232.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 4050.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 455.72, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 4050.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Remove mandible cyst complex", "code_information": [ { "code": "21046", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4360.43, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3229.95, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 36478.48, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 66190.81, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4360.43, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 66190.81, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Remove mastoid air cells", "code_information": [ { "code": "69670", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4360.43, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3229.95, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 24962.16, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 45294.24, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4360.43, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 45294.24, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Remove mastoid structures", "code_information": [ { "code": "69505", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4360.43, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3229.95, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 12910.75, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 23426.78, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4360.43, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 23426.78, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Remove maxilla cyst complex", "code_information": [ { "code": "21048", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4360.43, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3229.95, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 13004.95, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 23597.69, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4360.43, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 23597.69, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Remove muti-comp penis pros", "code_information": [ { "code": "54406", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2542.24, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1883.14, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 8045.06, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 14597.91, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2542.24, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 14597.91, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Remove nasal foreign body", "code_information": [ { "code": "30310", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2390.47, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1770.72, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 9550.54, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 17329.6, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2390.47, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 17329.6, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Remove nerve lesion", "code_information": [ { "code": "64784", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1439.39, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1066.21, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 11845.79, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 21494.38, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1439.39, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 21494.38, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Remove palate/lesion", "code_information": [ { "code": "42120", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4360.43, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3229.95, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 9047.12, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 16416.14, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4360.43, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 16416.14, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Remove part of temporal bone", "code_information": [ { "code": "69535", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 52278.8, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 95144.57, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 95144.57, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Remove pituit tumor w/scope", "code_information": [ { "code": "62165", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 37198.84, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 69911.7, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 69911.7, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Remove prostate regrowth", "code_information": [ { "code": "52630", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 3747.14, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2775.66, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 10478.01, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 19030.5, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3747.14, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 19030.5, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Remove pulse generator", "code_information": [ { "code": "33241", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2682.53, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1987.06, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 23936.14, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 43432.53, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2682.53, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 43432.53, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Remove renal tube w/fluoro", "code_information": [ { "code": "50389", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 491.99, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 364.44, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 15496.23, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 28118.17, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 491.99, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 28118.17, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Remove sciatic nerve lesion", "code_information": [ { "code": "64786", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4720.44, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3496.62, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 17209.22, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 31226.43, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4720.44, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 31226.43, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Remove shoulder bone part", "code_information": [ { "code": "23130", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2391.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1771.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 17972.77, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 32611.88, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2391.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 32611.88, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Remove skin nerve lesion", "code_information": [ { "code": "64774", "type": "HCPCS" }, { "code": "64788", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1439.39, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1066.21, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 33950.77, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 61604.24, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1439.39, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 61604.24, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Remove spinal canal catheter", "code_information": [ { "code": "62355", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1439.39, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1066.21, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 15215.8, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 27609.3, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1439.39, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 27609.3, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Remove spine eltrd perq aray", "code_information": [ { "code": "63661", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1439.39, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1066.21, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 9667.04, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 17541.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1439.39, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 17541.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Remove spine eltrd plate", "code_information": [ { "code": "63662", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2534.89, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1877.7, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 14076.57, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 25542.19, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2534.89, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 25542.19, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Remove spine fixation device", "code_information": [ { "code": "22852", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 17508.46, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 31769.4, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 31769.4, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Remove spine infusion device", "code_information": [ { "code": "62365", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4720.44, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3496.62, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 6960.37, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 12629.7, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4720.44, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 12629.7, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Remove stent via transureth", "code_information": [ { "code": "50386", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1509.96, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1118.49, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 13058.14, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 23694.22, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1509.96, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 23694.22, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Remove tendon sheath lesion", "code_information": [ { "code": "26160", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1179.66, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 873.82, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 4871.7, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 8839.8, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1179.66, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 8839.8, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Remove thyroid duct lesion", "code_information": [ { "code": "60280", "type": "HCPCS" }, { "code": "60281", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4300.51, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3185.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 19000.43, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 34476.59, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4300.51, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 34476.59, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Remove thyroid lesion", "code_information": [ { "code": "60200", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4300.51, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3185.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 13974.31, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 25356.6, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4300.51, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 25356.6, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Remove tonsils and adenoids", "code_information": [ { "code": "42820", "type": "HCPCS" }, { "code": "42821", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4360.43, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3229.95, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1770.72, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 6879.01, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 12486.14, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4360.43, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2390.47, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 12486.14, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Remove tunneled ip cath", "code_information": [ { "code": "49422", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2320.02, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1718.54, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 8712.24, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 15808.5, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2320.02, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 15808.5, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Remove ureter stent percut", "code_information": [ { "code": "50384", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1509.96, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1118.49, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 12941.96, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 23483.39, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1509.96, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 23483.39, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Remove uro sphincter", "code_information": [ { "code": "53446", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 3747.14, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2775.66, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 11710.56, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 21249.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3747.14, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 21249.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Remove vagina gland lesion", "code_information": [ { "code": "56740", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2343.63, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1736.02, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 10758.33, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 20495.35, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2343.63, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 20495.35, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Remove vagina lesion", "code_information": [ { "code": "57130", "type": "HCPCS" }, { "code": "57135", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2343.63, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1736.02, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 10654.01, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 19331.87, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2343.63, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 19331.87, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Remove vagina wall partial", "code_information": [ { "code": "57106", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2343.63, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1736.02, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 35257.13, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 63974.66, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2343.63, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 63974.66, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Remove vaginal foreign body", "code_information": [ { "code": "57415", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2343.63, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1736.02, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 6707.9, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 12171.6, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2343.63, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 12171.6, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Remove vagus n eltrd", "code_information": [ { "code": "64570", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4720.44, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3496.62, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 19037.55, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 34543.94, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4720.44, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 34543.94, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Remove vc lesion w/scope", "code_information": [ { "code": "31545", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2717.65, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2013.07, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 10829.7, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 19650.67, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2717.65, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 19650.67, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Remove ventilating tube", "code_information": [ { "code": "69424", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2390.47, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1770.72, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 3717.76, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 6745.95, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2390.47, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 6745.95, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Remove vert body dcmprn crvl", "code_information": [ { "code": "63081", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 82140.74, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 149539.78, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 149539.78, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Remove wrist joint cartilage", "code_information": [ { "code": "25107", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2391.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1771.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 12046.85, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 21859.2, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2391.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 21859.2, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Remove wrist joint implant", "code_information": [ { "code": "25449", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 5265.64, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3900.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 15543.38, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 28203.71, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5265.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 28203.71, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Remove wrist joint lining", "code_information": [ { "code": "25105", "type": "HCPCS" }, { "code": "26130", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2391.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1771.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 9083.25, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 16481.7, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2391.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 16481.7, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Remove wrist tendon lesion", "code_information": [ { "code": "25110", "type": "HCPCS" }, { "code": "25111", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1179.66, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 873.82, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 8208.8, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 14895.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1179.66, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 14895.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Remove wrist/forearm lesion", "code_information": [ { "code": "25115", "type": "HCPCS" }, { "code": "25116", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2391.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 873.82, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1771.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 17539.28, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 31825.33, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1179.66, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2391.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 31825.33, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Remove&replace pm gen singl", "code_information": [ { "code": "33227", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 6100.22, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4518.69, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 25368.24, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 46031.08, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6100.22, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 46031.08, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Remove/graft bone lesion", "code_information": [ { "code": "26205", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 5265.64, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3900.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 23066.17, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 41853.93, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5265.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 41853.93, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Remove/graft foot lesion", "code_information": [ { "code": "28103", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 5265.64, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3900.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 13145.58, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 23852.86, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5265.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 23852.86, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Remove/graft forearm lesion", "code_information": [ { "code": "25126", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2391.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1771.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 13045.7, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 24602.26, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2391.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 24602.26, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Remove/graft leg bone lesion", "code_information": [ { "code": "27637", "type": "HCPCS" }, { "code": "27638", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 5265.64, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3900.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 25749.93, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 46723.72, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5265.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 46723.72, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Remove/insert drug implant", "code_information": [ { "code": "11983", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 294.13, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 2836.54, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 5146.96, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 294.13, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 5146.96, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Remove/repair hearing aid", "code_information": [ { "code": "69711", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2390.47, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1770.72, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 33143.31, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 60139.03, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2390.47, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 60139.03, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Remove/replace penis prosth", "code_information": [ { "code": "54410", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 14836.76, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 10990.19, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 34581.1, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 62748.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 14836.76, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 62748.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Remove/replace ur sphincter", "code_information": [ { "code": "53447", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 14836.76, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 10990.19, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 44297.71, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 80378.9, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 14836.76, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 80378.9, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Remove/revise male sling", "code_information": [ { "code": "53442", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 3747.14, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue 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75.0, "estimated_amount": 11263.5, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Remove/transplant tendon", "code_information": [ { "code": "23440", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 5265.64, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3900.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 40627.02, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 73718.4, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5265.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 73718.4, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Remv&replc pm gen dual lead", "code_information": [ { "code": "33228", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 7713.99, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5714.07, "standard_charge_percentage": 100.0, "methodology": "fee 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leads", "code_information": [ { "code": "33229", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 14057.35, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 10412.85, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 24123.38, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 43772.28, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 14057.35, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 43772.28, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Remv/repl penis contain pros", "code_information": [ { "code": "54416", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 14836.76, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 10990.19, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 37069.67, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 67263.53, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 14836.76, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 67263.53, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "RENA-VITE PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "R6025816001", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "RENA-VITE RX 1 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60258016101", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Renal biopsy perq", "code_information": [ { "code": "50200", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1194.28, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 884.65, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 2916.48, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare 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Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2695.3, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 15343.81, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 27841.58, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3638.66, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 27841.58, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "REPAGLINIDE 0.5 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "3334224811", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, 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"standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "REPAGLINIDE 1 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687056021", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.43, "maximum": 4.78, "gross_charge": 5.09, "discounted_cash": 2.8, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.95, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.78, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.07, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.31, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.48, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.44, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.05, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.04, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.78, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.48, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.43, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.33, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.82, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.79, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.46, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.78, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.99, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.78, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.05, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.82, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.48, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.95, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.78, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "REPAGLINIDE 2 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "3334225011", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Repair achilles tendon", "code_information": [ { "code": "27650", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 5265.64, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3900.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 11719.21, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 21264.69, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5265.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 21264.69, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Repair anal fistula", "code_information": [ { "code": "46288", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2021.42, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1497.34, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 9522.78, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 17279.24, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2021.42, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 17279.24, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Repair biceps tendon", "code_information": [ { "code": "23430", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 5265.64, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3900.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 21668.14, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 39317.19, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5265.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 39317.19, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Repair bladder defect", "code_information": [ { "code": "57288", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 3638.66, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2695.3, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 12589.54, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 22856.37, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3638.66, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 22856.37, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Repair bladder neck", "code_information": [ { "code": "51845", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 3638.66, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2695.3, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 23354.68, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 42434.51, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3638.66, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 42434.51, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Repair bladder-vagina lesion", "code_information": [ { "code": "57320", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 3638.66, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2695.3, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 30805.14, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 56024.07, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3638.66, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 56024.07, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Repair bladder/vagina lesion", "code_information": [ { "code": "51900", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 36093.24, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 65887.08, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 65887.08, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Repair blood vessel lesion", "code_information": [ { "code": "35190", "type": "HCPCS" }, { "code": "35206", "type": "HCPCS" }, { "code": "35207", "type": "HCPCS" }, { "code": "35226", "type": "HCPCS" }, { "code": "35236", "type": "HCPCS" }, { "code": "35266", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 3984.54, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2951.51, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1718.54, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 384.16, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 31489.07, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 57137.42, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3984.54, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2320.02, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 518.62, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 57137.42, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Repair bowel fistula", "code_information": [ { "code": "44650", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 3493.89, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 6339.73, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 6339.73, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Repair bowel opening", "code_information": [ { "code": "44620", "type": "HCPCS" }, { "code": "44625", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 14867.51, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 26977.33, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 26977.33, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Repair brain fluid leakage", "code_information": [ { "code": "62100", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 25762.65, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 46768.59, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 46768.59, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Repair brow defect", "code_information": [ { "code": "67900", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1719.62, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1273.8, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 9582.31, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 17387.27, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1719.62, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 17387.27, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Repair cleft lip/nasal", "code_information": [ { "code": "40700", "type": "HCPCS" }, { "code": "40701", "type": "HCPCS" }, { "code": "40720", "type": "HCPCS" }, { "code": "40761", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4360.43, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3229.95, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1770.72, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 15684.77, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 28460.25, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4360.43, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2390.47, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 28460.25, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Repair clitoris", "code_information": [ { "code": "56805", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2343.63, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1736.02, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 32426.67, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 58838.75, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2343.63, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 58838.75, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Repair defect of arm artery", "code_information": [ { "code": "35045", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 3984.54, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2951.51, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 16512.82, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 29962.81, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3984.54, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 29962.81, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Repair defect of artery", "code_information": [ { "code": "35011", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 3984.54, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2951.51, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 15732.96, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 28547.71, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3984.54, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 28547.71, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Repair deformity of toe", "code_information": [ { "code": "28313", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2391.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1771.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 14096.67, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 25578.64, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2391.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 25578.64, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Repair degenerated kneecap", "code_information": [ { "code": "27418", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 5265.64, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3900.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 34820.55, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 63182.46, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5265.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 63182.46, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Repair detached retina", "code_information": [ { "code": "67107", "type": "HCPCS" }, { "code": "67108", "type": "HCPCS" }, { "code": "67110", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2965.25, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2196.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1245.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 13268.18, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 24075.31, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2965.25, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1681.13, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 24075.31, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Repair detached retina crtx", "code_information": [ { "code": "67101", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1681.13, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1245.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 2604.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 4856.09, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1681.13, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 4856.09, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Repair dura", "code_information": [ { "code": "61618", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 33529.69, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 60840.25, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 60840.25, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Repair eardrum structures", "code_information": [ { "code": "69631", "type": "HCPCS" }, { "code": "69635", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4360.43, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3229.95, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 13889.56, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 25202.84, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4360.43, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 25202.84, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Repair elbow deb/attch open", "code_information": [ { "code": "24359", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2391.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1771.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 11565.2, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 20985.25, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2391.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 20985.25, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Repair elbow perc", "code_information": [ { "code": "24357", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2391.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1771.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 12173.61, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 22089.24, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2391.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 22089.24, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Repair elbow w/deb open", "code_information": [ { "code": "24358", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2391.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1771.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 12397.15, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 22502.65, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2391.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 22502.65, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Repair esophagus opening", "code_information": [ { "code": "43420", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2390.47, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1770.72, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 9008.36, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 16345.81, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2390.47, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 16345.81, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Repair extra toe(s)", "code_information": [ { "code": "28344", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2391.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1771.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 8477.14, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 15381.9, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2391.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 15381.9, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Repair eyelid defect", "code_information": [ { "code": "67901", "type": "HCPCS" }, { "code": "67902", "type": "HCPCS" }, { "code": "67903", "type": "HCPCS" }, { "code": "67904", "type": "HCPCS" }, { "code": "67906", "type": "HCPCS" }, { "code": "67908", "type": "HCPCS" }, { "code": "67914", "type": "HCPCS" }, { "code": "67916", "type": "HCPCS" }, { "code": "67917", "type": "HCPCS" }, { "code": "67921", "type": "HCPCS" }, { "code": "67923", "type": "HCPCS" }, { "code": "67924", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2779.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1273.8, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2058.97, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 6418.78, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 11646.97, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1719.62, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2779.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 11646.97, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Repair fibula nonunion", "code_information": [ { "code": "27726", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 5265.64, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3900.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 11984.57, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 21746.19, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5265.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 21746.19, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Repair finger tendon", "code_information": [ { "code": "26418", "type": "HCPCS" }, { "code": "26432", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1179.66, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 873.82, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 6592.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 11961.29, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1179.66, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 11961.29, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Repair finger/hand tendon", "code_information": [ { "code": "26350", "type": "HCPCS" }, { "code": "26356", "type": "HCPCS" }, { "code": "26357", "type": "HCPCS" }, { "code": "26370", "type": "HCPCS" }, { "code": "26426", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2391.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1771.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 11401.48, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 20688.17, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2391.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 20688.17, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Repair foot dislocation", "code_information": [ { "code": "28615", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 5265.64, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3900.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 33868.08, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 61454.21, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5265.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 61454.21, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Repair forearm tendon sheath", "code_information": [ { "code": "25275", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2391.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1771.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 9669.79, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 17546.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2391.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 17546.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Repair forearm tendon/muscle", "code_information": [ { "code": "25260", "type": "HCPCS" }, { "code": "25270", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2391.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1771.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 15139.14, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 27470.21, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2391.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 27470.21, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Repair gum", "code_information": [ { "code": "41872", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2390.47, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1770.72, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 4805.69, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 8719.99, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2390.47, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 8719.99, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Repair hand joint", "code_information": [ { "code": "26540", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2391.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1771.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 11532.6, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 20926.1, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2391.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 20926.1, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Repair hand joint with graft", "code_information": [ { "code": "26541", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2391.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1771.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 9893.57, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 17952.05, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2391.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 17952.05, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Repair hand tendon", "code_information": [ { "code": "26410", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1179.66, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 873.82, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 9697.04, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 17595.45, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1179.66, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 17595.45, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Repair humerus with graft", "code_information": [ { "code": "24435", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 9484.13, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 7025.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 25336.31, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 45973.17, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 9484.13, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 45973.17, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Repair ing hernia sliding", "code_information": [ { "code": "49525", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2601.27, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1926.87, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 10439.77, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 18943.14, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2601.27, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 18943.14, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Repair iris & ciliary body", "code_information": [ { "code": "66680", "type": "HCPCS" }, { "code": "66682", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1681.13, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1245.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 12326.34, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 22366.35, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1681.13, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 22366.35, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Repair lac palate<2 cm", "code_information": [ { "code": "42180", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 375.37, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 278.05, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 16818.07, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 30516.65, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 375.37, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 30516.65, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Repair lead pace-defib dual", "code_information": [ { "code": "33220", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2682.53, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1987.06, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 44846.77, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 81375.2, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2682.53, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 81375.2, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Repair lead pace-defib one", "code_information": [ { "code": "33218", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2682.53, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1987.06, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 23345.92, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 42365.17, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2682.53, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 42365.17, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Repair lower leg epiphyses", "code_information": [ { "code": "27734", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2391.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1771.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 12581.04, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 22828.49, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2391.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 22828.49, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Repair lower leg tendons", "code_information": [ { "code": "27675", "type": "HCPCS" }, { "code": "27676", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 5265.64, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1771.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3900.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 37702.35, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 68411.48, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2391.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5265.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 68411.48, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Repair middle ear structures", "code_information": [ { "code": "69666", "type": "HCPCS" }, { "code": "69667", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2390.47, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1770.72, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 11834.6, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 21474.11, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2390.47, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 21474.11, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Repair mouth/nose fistula", "code_information": [ { "code": "30600", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4360.43, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3229.95, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 18329.7, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 33259.54, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4360.43, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 33259.54, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Repair multi-comp penis pros", "code_information": [ { "code": "54408", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 3747.14, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2775.66, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 16377.89, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 29780.18, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3747.14, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 29780.18, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Repair muscles of hand", "code_information": [ { "code": "26591", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2391.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1771.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 12112.04, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 21977.52, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2391.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 21977.52, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Repair nasal septum defect", "code_information": [ { "code": "30630", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2390.47, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1770.72, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 14171.23, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 25713.91, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2390.47, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 25713.91, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Repair nasal stenosis", "code_information": [ { "code": "30465", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4360.43, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3229.95, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 20745.65, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 37643.38, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4360.43, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 37643.38, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Repair nonunion hand", "code_information": [ { "code": "26546", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 5265.64, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3900.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 10512.59, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 19075.3, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5265.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 19075.3, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Repair of achilles tendon", "code_information": [ { "code": "27654", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 5265.64, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3900.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 9008.84, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 16346.7, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5265.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 16346.7, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Repair of anal sphincter", "code_information": [ { "code": "46750", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2021.42, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1497.34, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 20990.48, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 38087.64, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2021.42, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 38087.64, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Repair of anal stricture", "code_information": [ { "code": "46705", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 16381.44, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 29724.41, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 29724.41, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Repair of ankle ligament", "code_information": [ { "code": "27695", "type": "HCPCS" }, { "code": "27698", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 5265.64, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3900.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 19363.44, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 35223.49, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5265.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 35223.49, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Repair of ankle ligaments", "code_information": [ { "code": "27696", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 5265.64, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3900.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 11801.82, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 21414.6, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5265.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 21414.6, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Repair of bladder opening", "code_information": [ { "code": "51880", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2542.24, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1883.14, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 16696.83, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 30296.7, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2542.24, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 30296.7, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Repair of bladder wound", "code_information": [ { "code": "51860", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 6816.07, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5048.94, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 26504.75, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 48093.29, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6816.07, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 48093.29, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Repair of circumcision", "code_information": [ { "code": "54163", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1509.96, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1118.49, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 8646.94, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 15690.02, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1509.96, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 15690.02, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Repair of digit nerve", "code_information": [ { "code": "64831", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1439.39, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1066.21, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 10914.54, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 19804.64, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1439.39, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 19804.64, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Repair of eardrum", "code_information": [ { "code": "69610", "type": "HCPCS" }, { "code": "69620", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2390.47, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 808.78, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1770.72, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 5664.32, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 10278.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1091.85, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2390.47, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 10278.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Repair of eye socket wound", "code_information": [ { "code": "65290", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2779.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2058.97, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 9441.93, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 17132.52, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2779.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 17132.52, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Repair of eye wound", "code_information": [ { "code": "65275", "type": "HCPCS" }, { "code": "65280", "type": "HCPCS" }, { "code": "65286", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 3803.22, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2058.97, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2817.2, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1245.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 6254.63, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 11349.1, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2779.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3803.22, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1681.13, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 11349.1, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Repair of foot tendon", "code_information": [ { "code": "28200", "type": "HCPCS" }, { "code": "28208", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2391.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1771.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 11759.66, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 21338.1, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2391.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 21338.1, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Repair of hammertoe", "code_information": [ { "code": "28285", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2391.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1771.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 8323.38, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 15102.9, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2391.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 15102.9, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Repair of hand or foot nerve", "code_information": [ { "code": "64834", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4720.44, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3496.62, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 7644.84, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 13875.3, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4720.44, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 13875.3, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Repair of humerus", "code_information": [ { "code": "24430", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 9484.13, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 7025.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 25296.01, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 45900.03, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 9484.13, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 45900.03, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Repair of hydrocele", "code_information": [ { "code": "55060", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2542.24, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1883.14, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 7291.81, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 13231.11, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2542.24, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 13231.11, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Repair of knee cartilage", "code_information": [ { "code": "27403", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 5265.64, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3900.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 21517.57, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 39043.99, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5265.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 39043.99, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Repair of knee ligament", "code_information": [ { "code": "27405", "type": "HCPCS" }, { "code": "27407", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 5265.64, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3900.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 20799.21, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 37740.51, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5265.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 37740.51, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Repair of kneecap tendon", "code_information": [ { "code": "27380", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 5265.64, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3900.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 19560.64, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 35493.1, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5265.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 35493.1, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Repair of leg tendon each", "code_information": [ { "code": "27658", "type": "HCPCS" }, { "code": "27659", "type": "HCPCS" }, { "code": "27665", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 5265.64, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1771.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3900.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 22496.09, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 40819.56, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2391.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5265.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 40819.56, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Repair of metatarsals", "code_information": [ { "code": "28322", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 5265.64, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3900.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 15662.22, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 28419.34, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5265.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 28419.34, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Repair of nasal septum", "code_information": [ { "code": "30520", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2390.47, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1770.72, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 17033.14, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 30906.91, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2390.47, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 30906.91, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Repair of perineum", "code_information": [ { "code": "56810", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2343.63, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1736.02, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 9948.05, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 18050.9, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2343.63, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 18050.9, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Repair of ruptured tendon", "code_information": [ { "code": "24342", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 5265.64, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3900.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 13874.52, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 25175.53, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5265.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 25175.53, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Repair of shoulder", "code_information": [ { "code": "23420", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 5265.64, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3900.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 24993.85, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 45351.75, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5265.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 45351.75, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Repair of sperm duct", "code_information": [ { "code": "55400", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2542.24, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1883.14, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 16335.13, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 29640.35, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2542.24, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 29640.35, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Repair of thigh", "code_information": [ { "code": "27470", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 15793.46, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 28657.47, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 28657.47, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Repair of thigh muscle", "code_information": [ { "code": "27385", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 5265.64, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3900.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 14418.59, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 26162.76, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5265.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 26162.76, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Repair of tibia", "code_information": [ { "code": "27720", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 5265.64, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3900.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 27986.92, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 50782.71, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5265.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 50782.71, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Repair of tibia epiphysis", "code_information": [ { "code": "27730", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2391.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1771.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 7440.88, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 13501.6, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2391.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 13501.6, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Repair of toe dislocation", "code_information": [ { "code": "28675", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2391.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1771.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 6600.77, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 11977.2, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2391.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 11977.2, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Repair of urethra defect", "code_information": [ { "code": "53275", "type": "HCPCS" }, { "code": "53520", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 3747.14, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1883.14, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2775.66, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 7481.66, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 13575.6, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2542.24, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3747.14, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 13575.6, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Repair of urethra injury", "code_information": [ { "code": "53502", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2542.24, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1883.14, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 44470.76, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 80693.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2542.24, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 80693.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Repair of vagina", "code_information": [ { "code": "56800", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2343.63, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1736.02, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 11014.12, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 19985.29, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2343.63, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 19985.29, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Repair of web finger", "code_information": [ { "code": "26561", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2391.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1771.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 13846.95, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 25125.51, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2391.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 25125.51, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Repair of windpipe", "code_information": [ { "code": "31750", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4360.43, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3229.95, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 16718.35, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 30335.81, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4360.43, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 30335.81, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Repair of windpipe defect", "code_information": [ { "code": "31825", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2390.47, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1770.72, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 9865.76, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 17901.58, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2390.47, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 17901.58, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Repair palate", "code_information": [ { "code": "42182", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4360.43, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3229.95, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 28312.67, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 51373.8, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4360.43, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 51373.8, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Repair palate pharynx/uvula", "code_information": [ { "code": "42145", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4360.43, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3229.95, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 15069.05, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 27404.93, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4360.43, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 27404.93, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Repair paravag defect open", "code_information": [ { "code": "57284", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 3638.66, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2695.3, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 13878.58, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 25182.89, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3638.66, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 25182.89, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Repair paravag defect vag", "code_information": [ { "code": "57285", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 5450.71, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4037.57, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 15759.5, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 28595.9, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5450.71, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 28595.9, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Repair radius or ulna", "code_information": [ { "code": "25400", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 5265.64, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3900.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 15496.83, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 28119.24, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5265.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 28119.24, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Repair rectum & vagina", "code_information": [ { "code": "57250", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 3638.66, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2695.3, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 16138.39, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 29283.37, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3638.66, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 29283.37, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Repair rectum-vagina fistula", "code_information": [ { "code": "57300", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2343.63, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1736.02, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 16243.49, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 29474.1, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2343.63, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 29474.1, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Repair retinal detach cplx", "code_information": [ { "code": "67113", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 3803.22, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2817.2, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 15372.89, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 27894.35, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3803.22, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 27894.35, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Repair rotator cuff acute", "code_information": [ { "code": "23410", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 5265.64, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3900.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 19871.52, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 36060.86, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5265.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 36060.86, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Repair rotator cuff chronic", "code_information": [ { "code": "23412", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 5265.64, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3900.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 28576.26, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 51852.1, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5265.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 51852.1, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Repair salivary duct", "code_information": [ { "code": "42500", "type": "HCPCS" }, { "code": "42505", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4360.43, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3229.95, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 29773.48, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 54024.48, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4360.43, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 54024.48, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Repair shoulder capsule", "code_information": [ { "code": "23455", "type": "HCPCS" }, { "code": "23460", "type": "HCPCS" }, { "code": "23462", "type": "HCPCS" }, { "code": "23465", "type": "HCPCS" }, { "code": "23466", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 5265.64, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3900.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 17029.87, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 30900.97, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5265.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 30900.97, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Repair skull cavity lesion", "code_information": [ { "code": "62120", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 17658.08, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 33114.51, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 33114.51, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Repair spinal fluid leakage", "code_information": [ { "code": "63709", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 21752.66, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 39871.22, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 39871.22, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Repair sternum/nuss w/scope", "code_information": [ { "code": "21743", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2391.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1771.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 41561.03, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 75433.53, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2391.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 75433.53, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Repair stomach opening", "code_information": [ { "code": "43870", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2804.32, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2077.27, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 5188.16, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 9417.6, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2804.32, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 9417.6, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Repair tear ducts", "code_information": [ { "code": "68700", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1719.62, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1273.8, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 7046.98, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 12786.91, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1719.62, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 12786.91, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Repair toe dislocation", "code_information": [ { "code": "28645", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2391.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1771.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 6860.18, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 12447.9, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2391.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 12447.9, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Repair tooth socket", "code_information": [ { "code": "41874", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2390.47, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1770.72, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 13004.95, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 23597.69, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2390.47, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 23597.69, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Repair umbilical lesion", "code_information": [ { "code": "49600", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2601.27, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1926.87, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 15583.35, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 28276.26, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2601.27, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 28276.26, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Repair upper jaw fistula", "code_information": [ { "code": "30580", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4360.43, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3229.95, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 8965.69, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 16785.91, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4360.43, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 16785.91, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Repair urethrovaginal lesion", "code_information": [ { "code": "57310", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 5450.71, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4037.57, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 12589.54, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 22856.37, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5450.71, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 22856.37, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Repair uro sphincter", "code_information": [ { "code": "53449", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 6816.07, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5048.94, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 5931.66, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 10763.1, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6816.07, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 10763.1, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Repair webbed toe(s)", "code_information": [ { "code": "28345", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1179.66, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 873.82, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 8477.14, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 15381.9, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1179.66, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 15381.9, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Repair windpipe opening", "code_information": [ { "code": "31613", "type": "HCPCS" }, { "code": "31614", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4360.43, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1770.72, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3229.95, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 8949.16, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 16238.38, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2390.47, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4360.43, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 16238.38, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Repair wrist joints", "code_information": [ { "code": "25447", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2391.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1771.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 15395.64, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 27935.63, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2391.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 27935.63, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Repair/graft achilles tendon", "code_information": [ { "code": "27652", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 5265.64, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3900.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 25141.79, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 45620.17, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5265.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 45620.17, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Repair/graft femur head/neck", "code_information": [ { "code": "27170", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 25248.75, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 45814.3, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 45814.3, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Repair/graft finger tendon", "code_information": [ { "code": "26420", "type": "HCPCS" }, { "code": "26428", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2391.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1771.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 6066.08, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 11052.84, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2391.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 11052.84, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Repair/graft hand tendon", "code_information": [ { "code": "26352", "type": "HCPCS" }, { "code": "26358", "type": "HCPCS" }, { "code": "26372", "type": "HCPCS" }, { "code": "26392", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 5265.64, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3900.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 11044.93, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 20041.2, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5265.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 20041.2, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Repair/graft kneecap tendon", "code_information": [ { "code": "27381", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 5265.64, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3900.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 18173.16, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 32975.48, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5265.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 32975.48, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Repair/graft of foot tendon", "code_information": [ { "code": "28202", "type": "HCPCS" }, { "code": "28210", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 5265.64, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3900.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 21637.7, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 39261.98, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5265.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 39261.98, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Repair/graft of thigh", "code_information": [ { "code": "27472", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 36078.82, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 65812.12, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 65812.12, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Repair/graft of thigh muscle", "code_information": [ { "code": "27386", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 5265.64, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3900.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 22453.55, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 40742.35, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5265.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 40742.35, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Repair/graft of tibia", "code_information": [ { "code": "27724", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 25114.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 45569.74, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 45569.74, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Repair/graft radius or ulna", "code_information": [ { "code": "25405", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 5265.64, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3900.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 50449.11, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 91540.79, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5265.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 91540.79, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Repair/graft wrist bone", "code_information": [ { "code": "25440", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 5265.64, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3900.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 11305.26, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 20513.57, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5265.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 20513.57, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Repair/revise wrist joint", "code_information": [ { "code": "25320", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 5265.64, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3900.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 12047.84, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 21861.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5265.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 21861.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Repeat thyroid surgery", "code_information": [ { "code": "60260", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4360.43, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3229.95, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 15110.04, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 27417.43, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4360.43, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 27417.43, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Replace brain cavity shunt", "code_information": [ { "code": "62258", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 29277.91, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 53125.26, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 53125.26, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Replace duod/jej tube perc", "code_information": [ { "code": "49451", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 691.08, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 511.91, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 7780.5, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 14117.87, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 691.08, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 14117.87, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Replace elbow joint", "code_information": [ { "code": "24363", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 13555.31, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 10040.97, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 40184.19, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 72914.85, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 13555.31, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 72914.85, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Replace eye fluid", "code_information": [ { "code": "67025", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1681.13, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1245.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 8045.83, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 14599.25, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1681.13, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 14599.25, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Replace g-j tube perc", "code_information": [ { "code": "49452", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 691.08, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 511.91, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 8912.24, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 16171.43, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 691.08, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 16171.43, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Replace g/c tube perc", "code_information": [ { "code": "49450", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 691.08, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 511.91, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 8010.93, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 14535.98, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 691.08, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 14535.98, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Replace/irrigate catheter", "code_information": [ { "code": "62225", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4720.44, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3496.62, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 53935.1, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 97866.15, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4720.44, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 97866.15, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Replace/revise brain shunt", "code_information": [ { "code": "62230", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4720.44, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3496.62, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 25188.78, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 45705.53, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4720.44, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 45705.53, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Reposition intraocular lens", "code_information": [ { "code": "66825", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1681.13, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1245.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 6808.51, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 12354.15, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1681.13, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 12354.15, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Reposition pacing-defib lead", "code_information": [ { "code": "33215", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2320.02, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1718.54, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 20706.08, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 37571.54, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2320.02, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 37571.54, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Repr elbow lat ligmnt w/tiss", "code_information": [ { "code": "24343", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2391.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1771.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 20937.31, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 38002.5, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2391.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 38002.5, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Repr elbw med ligmnt w/tissu", "code_information": [ { "code": "24345", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 5265.64, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3900.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 23998.4, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 43545.48, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5265.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 43545.48, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Reremove wrist tendon lesion", "code_information": [ { "code": "25112", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1179.66, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 873.82, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 5581.05, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 10126.93, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1179.66, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 10126.93, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Rerepair fem hernia blocked", "code_information": [ { "code": "49557", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2601.27, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1926.87, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 27228.35, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 49406.32, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2601.27, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 49406.32, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Rerepair fem hernia reduce", "code_information": [ { "code": "49555", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2601.27, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1926.87, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 15954.99, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 28950.6, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2601.27, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 28950.6, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Rerepair ing hernia blocked", "code_information": [ { "code": "49521", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4599.32, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3406.9, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 8632.33, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 15663.5, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4599.32, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 15663.5, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Rerepair ing hernia reduce", "code_information": [ { "code": "49520", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2601.27, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1926.87, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 12533.85, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 22742.86, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2601.27, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 22742.86, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Resect back tum < 5 cm", "code_information": [ { "code": "21935", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2109.62, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1562.68, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 11927.81, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 21643.2, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2109.62, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 21643.2, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Resect back tum 5 cm/>", "code_information": [ { "code": "21936", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2109.62, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1562.68, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 11583.62, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 21018.66, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2109.62, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 21018.66, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Resect enlarged toe tissue", "code_information": [ { "code": "28340", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2391.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1771.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 11299.56, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 20503.24, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2391.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 20503.24, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Resect face/scalp tum < 2 cm", "code_information": [ { "code": "21015", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2109.62, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1562.68, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 3966.12, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 7196.58, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2109.62, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 7196.58, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Resect face/scalp tum 2 cm/>", "code_information": [ { "code": "21016", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2109.62, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1562.68, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 10639.94, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 19306.35, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2109.62, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 19306.35, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Resect femur/knee tumor", "code_information": [ { "code": "27365", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 13738.52, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 24928.77, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 24928.77, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Resect fibula tumor", "code_information": [ { "code": "27646", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 14669.88, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 26618.71, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 26618.71, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Resect foot/toe tumor 3 cm/>", "code_information": [ { "code": "28047", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2109.62, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1562.68, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 7410.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 13445.56, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2109.62, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 13445.56, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Resect forarm/wrist tum 3cm>", "code_information": [ { "code": "25078", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2109.62, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1562.68, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 9334.05, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 16936.78, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2109.62, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 16936.78, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Resect hip/pelv tum < 5 cm", "code_information": [ { "code": "27049", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2109.62, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1562.68, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 8172.1, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 14828.4, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2109.62, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 14828.4, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Resect hip/pelv tum 5 cm/>", "code_information": [ { "code": "27059", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2109.62, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1562.68, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 11270.4, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 20450.32, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2109.62, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 20450.32, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Resect inferior turbinate", "code_information": [ { "code": "30140", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2390.47, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1770.72, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 16885.51, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 30657.28, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2390.47, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 30657.28, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Resect leg/ankle tum < 5 cm", "code_information": [ { "code": "27615", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2109.62, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1562.68, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 5684.16, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 10314.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2109.62, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 10314.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Resect leg/ankle tum 5 cm/>", "code_information": [ { "code": "27616", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2109.62, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1562.68, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 9743.33, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 17679.43, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2109.62, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 17679.43, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Resect mediastinal tumor", "code_information": [ { "code": "39220", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 17954.63, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 32881.6, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 32881.6, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Resect neck thorax tumor<5cm", "code_information": [ { "code": "21557", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2109.62, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1562.68, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 13161.61, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 25627.97, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2109.62, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 25627.97, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Resect neck tumor 5 cm/>", "code_information": [ { "code": "21558", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2109.62, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1562.68, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 12273.23, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 22269.97, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2109.62, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 22269.97, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Resect prox humerus tumor", "code_information": [ { "code": "23220", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 74678.96, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 136981.84, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 136981.84, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Resect scapula tumor", "code_information": [ { "code": "23210", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 14805.5, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 26864.81, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 26864.81, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Resect shoulder tumor < 5 cm", "code_information": [ { "code": "23077", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2109.62, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1562.68, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 8033.7, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 14871.85, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2109.62, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 14871.85, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Resect shoulder tumor 5 cm/>", "code_information": [ { "code": "23078", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2109.62, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1562.68, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 9550.24, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 17329.07, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2109.62, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 17329.07, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Resect thigh/knee tum < 5 cm", "code_information": [ { "code": "27329", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2109.62, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1562.68, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 9365.14, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 16993.22, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2109.62, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 16993.22, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Resect thigh/knee tum 5 cm/>", "code_information": [ { "code": "27364", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2109.62, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1562.68, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 13112.02, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 23802.77, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2109.62, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 23802.77, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Resect tibia tumor", "code_information": [ { "code": "27645", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 49841.68, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 92703.2, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 92703.2, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Resect/excise cranial lesion", "code_information": [ { "code": "61600", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 34573.25, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 62733.79, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 62733.79, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Reset dislocated jaw", "code_information": [ { "code": "21485", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1091.85, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 808.78, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 21284.09, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 38620.33, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1091.85, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 38620.33, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "RESTYLANE 1 ML", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "04444000036", "type": "NDC" } ], "standard_charges": [ { "minimum": 243.2, "maximum": 1158.0, "gross_charge": 863.03, "discounted_cash": 474.67, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 500.56, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 471.21, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 749.11, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 251.14, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 414.25, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 516.95, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 516.09, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 811.25, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 759.47, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 243.2, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 733.58, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 647.27, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 304.05, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 586.86, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 811.25, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 675.75, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 471.21, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 686.11, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 647.27, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 759.47, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 500.56, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 471.21, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "RESTYLANE-L 0.5 ML", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "04444000037", "type": "NDC" } ], "standard_charges": [ { "minimum": 172.6, "maximum": 1158.0, "gross_charge": 612.5, "discounted_cash": 336.88, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 355.25, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 334.43, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 531.65, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 178.24, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 294.0, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 366.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 366.28, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 575.75, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 539.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 172.6, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 520.63, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 459.38, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 215.78, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 416.5, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 575.75, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 479.59, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 334.43, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 486.94, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 459.38, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 539.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 355.25, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 334.43, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "RESTYLANE-L 1 ML", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00299596713", "type": "NDC" } ], "standard_charges": [ { "minimum": 299.08, "maximum": 1158.0, "gross_charge": 1061.32, "discounted_cash": 583.73, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 615.57, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 579.48, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 921.23, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 308.84, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 509.43, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 635.73, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 634.67, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 997.64, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 933.96, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 299.08, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 902.12, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 795.99, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 373.9, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 721.7, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 997.64, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 831.01, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 579.48, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 843.75, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 795.99, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 933.96, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 615.57, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 579.48, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "RESTYLANE-L LYFT 1 ML", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00299596312", "type": "NDC" } ], "standard_charges": [ { "minimum": 324.0, "maximum": 1158.0, "gross_charge": 1149.76, "discounted_cash": 632.37, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 666.86, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 627.77, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 997.99, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 334.58, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 551.88, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 688.71, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 687.56, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1080.77, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1011.79, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 324.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 977.3, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 862.32, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 405.06, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 781.84, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1080.77, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 900.26, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 627.77, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 914.06, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 862.32, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1011.79, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 666.86, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 627.77, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "RESTYLANE-L REFYNE 1 ML", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00299596410", "type": "NDC" } ], "standard_charges": [ { "minimum": 362.06, "maximum": 1207.71, "gross_charge": 1284.8, "discounted_cash": 706.64, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 745.18, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 701.5, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1115.21, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 373.88, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 616.7, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 769.6, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 768.31, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1207.71, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1130.62, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 362.06, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1092.08, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 963.6, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 452.64, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 873.66, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1207.71, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1006.0, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 701.5, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1021.42, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 963.6, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1130.62, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 745.18, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 701.5, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Rev/rmv imp sp npg/r dtch cn", "code_information": [ { "code": "63688", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2534.89, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1877.7, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 10288.65, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 18668.93, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2534.89, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 18668.93, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Rev/rmv perph nstim eltrd ra", "code_information": [ { "code": "64585", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2534.89, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1877.7, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 7479.68, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 13716.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2534.89, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 13716.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Rev/rmv prph sac/gstr npg/r", "code_information": [ { "code": "64595", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2534.89, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1877.7, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 8350.73, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 15152.54, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2534.89, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 15152.54, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Rev/rplct hpglsl nstm ary pg", "code_information": [ { "code": "64583", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 9191.87, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 6808.79, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 45802.06, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 83108.59, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 9191.87, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 83108.59, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Revasc intra lithotrip-ather", "code_information": [ { "code": "C9766", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 13235.9, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 9804.37, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 37516.89, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 68075.02, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 13235.9, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 68075.02, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Revasc intra lithotrip-stent", "code_information": [ { "code": "C9765", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 13235.9, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 9804.37, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 59600.85, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 108146.8, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 13235.9, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 108146.8, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Revasc intravasc lithotripsy", "code_information": [ { "code": "C9764", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 8359.13, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 6191.95, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 27025.65, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 49038.5, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8359.13, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 49038.5, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Revasc lithotr-stent tib/per", "code_information": [ { "code": "C9773", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 13235.9, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 9804.37, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 31688.75, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 57499.91, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 13235.9, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 57499.91, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Revasc lithotrip tibi/perone", "code_information": [ { "code": "C9772", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 8359.13, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 6191.95, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 39005.59, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 70776.31, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8359.13, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 70776.31, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Revasc lithotrip-stent-ather", "code_information": [ { "code": "C9767", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 13235.9, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 9804.37, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 30255.39, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 54898.92, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 13235.9, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 54898.92, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "REVEFENACIN 175 MCG/3ML IN SOLN", "drug_information": { "unit": "3.000000", "type": "UN" }, "code_information": [ { "code": "49502080693", "type": "NDC" } ], "standard_charges": [ { "minimum": 4.38, "maximum": 14.62, "gross_charge": 15.55, "discounted_cash": 8.55, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.02, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.49, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.44, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.53, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.46, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.31, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.3, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.62, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.68, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.38, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.22, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.66, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.48, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.57, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.62, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.18, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.49, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.36, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.66, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.68, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.02, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.49, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Revis reconst shoulder joint", "code_information": [ { "code": "23473", "type": "HCPCS" }, { "code": "23474", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 9484.13, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 7025.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 36370.81, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 65995.46, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 9484.13, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 65995.46, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Revise aqueous shunt eye", "code_information": [ { "code": "66185", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1681.13, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1245.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 7540.32, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 13682.03, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1681.13, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 13682.03, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Revise arm/leg nerve", "code_information": [ { "code": "64708", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1439.39, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1066.21, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 12577.25, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 22821.62, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1439.39, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 22821.62, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Revise cornea with implant", "code_information": [ { "code": "65770", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 10532.65, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 7801.96, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 25222.57, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 45766.73, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 10532.65, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 45766.73, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Revise external ear", "code_information": [ { "code": "69300", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2390.47, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1770.72, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 13629.21, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 24730.39, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2390.47, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 24730.39, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Revise eye muscle", "code_information": [ { "code": "67311", "type": "HCPCS" }, { "code": "67314", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1719.62, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1273.8, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 7262.62, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 13178.13, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1719.62, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 13178.13, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Revise eye muscle(s)", "code_information": [ { "code": "67318", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1719.62, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1273.8, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 7372.36, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 13377.29, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1719.62, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 13377.29, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Revise eye socket implant", "code_information": [ { "code": "67560", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2779.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2058.97, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 6909.86, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 12538.07, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2779.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 12538.07, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Revise eye with implant", "code_information": [ { "code": "65093", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2779.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2058.97, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 7043.62, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 12816.75, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2779.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 12816.75, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Revise eyelashes", "code_information": [ { "code": "67825", "type": "HCPCS" }, { "code": "67830", "type": "HCPCS" }, { "code": "67835", "type": "HCPCS" }, { "code": "67820", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1719.62, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 163.22, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 528.82, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1273.8, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 18549.75, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 33658.8, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 220.34, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 713.91, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1719.62, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 33658.8, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Revise eyelid defect", "code_information": [ { "code": "67909", "type": "HCPCS" }, { "code": "67911", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1719.62, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1273.8, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 5524.17, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 10095.73, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1719.62, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 10095.73, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Revise eyelid lining", "code_information": [ { "code": "68330", "type": "HCPCS" }, { "code": "68360", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2779.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1245.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2058.97, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 11269.69, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 20449.06, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1681.13, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2779.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 20449.06, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Revise finger joint", "code_information": [ { "code": "26535", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2391.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1771.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 15030.4, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 27272.92, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2391.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 27272.92, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Revise finger joint each", "code_information": [ { "code": "26135", "type": "HCPCS" }, { "code": "26140", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2391.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1771.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 873.82, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 4977.59, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 9031.91, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2391.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1179.66, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 9031.91, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Revise finger/toe nerve", "code_information": [ { "code": "64702", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1439.39, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1066.21, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 7268.5, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 13188.81, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1439.39, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 13188.81, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Revise hand/finger tendon", "code_information": [ { "code": "26390", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 5265.64, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3900.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 15641.48, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 28381.73, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5265.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 28381.73, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Revise hand/foot nerve", "code_information": [ { "code": "64704", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1439.39, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1066.21, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 8821.35, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 16572.28, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1439.39, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 16572.28, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Revise hernia & sperm veins", "code_information": [ { "code": "55540", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2601.27, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1926.87, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 8635.36, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 15669.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2601.27, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 15669.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Revise hip joint replacement", "code_information": [ { "code": "27134", "type": "HCPCS" }, { "code": "27138", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 80690.42, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 147322.82, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 147322.82, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Revise kneecap with implant", "code_information": [ { "code": "27438", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 9484.13, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 7025.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 30562.71, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 55476.16, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 9484.13, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 55476.16, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Revise knuckle joint", "code_information": [ { "code": "26530", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 5265.64, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3900.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 11967.48, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 21715.2, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5265.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 21715.2, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Revise knuckle with implant", "code_information": [ { "code": "26531", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 5265.64, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3900.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 15848.37, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 28757.12, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5265.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 28757.12, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Revise leg vein", "code_information": [ { "code": "37700", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2320.02, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1718.54, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 7298.64, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 13243.5, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2320.02, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 13243.5, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Revise low back nerve(s)", "code_information": [ { "code": "64714", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1439.39, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1066.21, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 27415.74, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 49746.33, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1439.39, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 49746.33, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Revise lower leg tendon", "code_information": [ { "code": "27690", "type": "HCPCS" }, { "code": "27691", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 5265.64, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3900.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 12265.6, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 22259.75, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5265.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 22259.75, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Revise lower leg tendons", "code_information": [ { "code": "27686", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2391.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1771.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 11235.27, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 20386.6, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2391.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 20386.6, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Revise middle ear & mastoid", "code_information": [ { "code": "69641", "type": "HCPCS" }, { "code": "69642", "type": "HCPCS" }, { "code": "69643", "type": "HCPCS" }, { "code": "69644", "type": "HCPCS" }, { "code": "69645", "type": "HCPCS" }, { "code": "69646", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4360.43, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3229.95, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 15000.27, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 27218.24, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4360.43, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 27218.24, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Revise middle ear bone", "code_information": [ { "code": "69660", "type": "HCPCS" }, { "code": "69661", "type": "HCPCS" }, { "code": "69662", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4360.43, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3229.95, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 11078.71, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 20595.98, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4360.43, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 20595.98, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Revise ocular implant", "code_information": [ { "code": "65150", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2779.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2058.97, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 6368.31, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 11555.4, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2779.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 11555.4, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Revise penis/urethra", "code_information": [ { "code": "54328", "type": "HCPCS" }, { "code": "54332", "type": "HCPCS" }, { "code": "54336", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2542.24, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1883.14, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 18815.76, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 34163.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2542.24, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 34163.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Revise prosth vag graft lap", "code_information": [ { "code": "57426", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 5450.71, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4037.57, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 37636.75, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 68292.47, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5450.71, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 68292.47, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Revise radius & ulna", "code_information": [ { "code": "25365", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 9484.13, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 7025.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 22923.49, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 41595.09, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 9484.13, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 41595.09, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Revise reconst elbow joint", "code_information": [ { "code": "24370", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 9484.13, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 7025.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 29082.54, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 52770.75, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 9484.13, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 52770.75, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Revise spermatic cord veins", "code_information": [ { "code": "55530", "type": "HCPCS" }, { "code": "55535", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4599.32, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1883.14, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3406.9, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 10735.92, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 19480.5, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2542.24, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4599.32, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 19480.5, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Revise spine eltrd perq aray", "code_information": [ { "code": "63663", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4837.51, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3583.34, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 23994.07, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 43692.65, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4837.51, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 43692.65, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Revise spine eltrd plate", "code_information": [ { "code": "63664", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 9191.87, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 6808.79, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 34426.64, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 62467.71, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 9191.87, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 62467.71, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Revise tear duct opening", "code_information": [ { "code": "68705", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 220.34, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 163.22, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 5260.67, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 9545.56, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 220.34, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 9545.56, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Revise thumb tendon", "code_information": [ { "code": "26496", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2391.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1771.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 11850.92, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 21503.7, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2391.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 21503.7, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Revise two eye muscles", "code_information": [ { "code": "67312", "type": "HCPCS" }, { "code": "67316", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2779.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2058.97, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1273.8, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 7578.88, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 13752.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2779.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1719.62, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 13752.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Revise ulnar nerve at elbow", "code_information": [ { "code": "64718", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1439.39, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1066.21, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 6835.86, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 12403.78, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1439.39, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 12403.78, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Revise ulnar nerve at wrist", "code_information": [ { "code": "64719", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1439.39, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1066.21, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 10824.37, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 19640.97, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1439.39, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 19640.97, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Revise ureter", "code_information": [ { "code": "50727", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2542.24, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1883.14, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 5879.31, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 10668.11, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2542.24, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 10668.11, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Revise urethra stage 1", "code_information": [ { "code": "53400", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 3747.14, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2775.66, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 13015.54, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 23616.9, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3747.14, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 23616.9, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Revise vag graft open abd", "code_information": [ { "code": "57296", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 15371.02, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 27890.97, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 27890.97, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Revise vag graft via vagina", "code_information": [ { "code": "57295", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2343.63, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1736.02, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 9179.35, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 16656.08, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2343.63, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 16656.08, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Revise windpipe scar", "code_information": [ { "code": "31830", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2390.47, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1770.72, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 19798.97, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 35925.53, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2390.47, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 35925.53, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Revise wrist joint", "code_information": [ { "code": "25332", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2391.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1771.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 10939.02, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 19849.05, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2391.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 19849.05, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Revise wrist/forearm tendon", "code_information": [ { "code": "25280", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2391.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1771.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 29381.78, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 53551.93, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2391.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 53551.93, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Revise/graft eyelid lining", "code_information": [ { "code": "68320", "type": "HCPCS" }, { "code": "68325", "type": "HCPCS" }, { "code": "68326", "type": "HCPCS" }, { "code": "68328", "type": "HCPCS" }, { "code": "68335", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2779.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1273.8, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2058.97, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 8350.65, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 15495.11, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1719.62, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2779.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 15495.11, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Revise/implant finger joint", "code_information": [ { "code": "26536", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 5265.64, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3900.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 8550.6, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 15515.21, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5265.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 15515.21, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Revise/remove neuroelectrode", "code_information": [ { "code": "61880", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2534.89, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1877.7, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 12656.11, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 22964.71, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2534.89, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 22964.71, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Revise/remove neuroreceiver", "code_information": [ { "code": "61888", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 9191.87, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 6808.79, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 12656.11, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 22964.71, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 9191.87, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 22964.71, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Revise/remove sling repair", "code_information": [ { "code": "57287", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2343.63, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1736.02, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 9211.83, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 16715.01, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2343.63, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 16715.01, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Revise/repl vagus n eltrd", "code_information": [ { "code": "64569", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 9191.87, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 6808.79, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 42949.97, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 77933.52, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 9191.87, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 77933.52, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Revise/replace knee joint", "code_information": [ { "code": "27486", "type": "HCPCS" }, { "code": "27487", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 21661.57, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 39305.27, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 39305.27, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Revision of ankle joint", "code_information": [ { "code": "27700", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 5265.64, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3900.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 13158.63, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 24228.45, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5265.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 24228.45, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Revision of aortic valve", "code_information": [ { "code": "92986", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4202.59, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3113.03, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 32795.62, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 59508.19, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4202.59, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 59508.19, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Revision of aqueous shunt", "code_information": [ { "code": "66184", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1681.13, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1245.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 6620.31, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 12012.66, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1681.13, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 12012.66, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Revision of arm nerve(s)", "code_information": [ { "code": "64713", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1439.39, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1066.21, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 21890.14, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 39720.04, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1439.39, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 39720.04, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Revision of big toe", "code_information": [ { "code": "28310", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 5265.64, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3900.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 13247.82, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 24038.38, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5265.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 24038.38, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Revision of bladder neck", "code_information": [ { "code": "52500", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2542.24, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1883.14, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 9124.66, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 16556.84, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2542.24, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 16556.84, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Revision of calf tendon", "code_information": [ { "code": "27687", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2391.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1771.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 14621.24, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 26530.45, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2391.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 26530.45, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Revision of cervix", "code_information": [ { "code": "57720", "type": "HCPCS" }, { "code": "59320", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2343.63, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1736.02, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 8383.63, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 15212.29, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2343.63, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 15212.29, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Revision of collar bone", "code_information": [ { "code": "23480", "type": "HCPCS" }, { "code": "23485", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 9484.13, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3900.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 7025.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 25219.16, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 45760.55, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5265.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 9484.13, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 45760.55, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Revision of colostomy", "code_information": [ { "code": "44340", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2698.5, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1998.89, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 5467.05, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 9920.05, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2698.5, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 9920.05, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Revision of cornea", "code_information": [ { "code": "65600", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1719.62, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1273.8, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 10232.3, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 18566.68, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1719.62, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 18566.68, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Revision of cranial nerve", "code_information": [ { "code": "64716", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1439.39, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1066.21, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 24777.63, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 44959.42, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1439.39, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 44959.42, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Revision of eyelid", "code_information": [ { "code": "21280", "type": "HCPCS" }, { "code": "21282", "type": "HCPCS" }, { "code": "67880", "type": "HCPCS" }, { "code": "67882", "type": "HCPCS" }, { "code": "67950", "type": "HCPCS" }, { "code": "67961", "type": "HCPCS" }, { "code": "67966", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2390.47, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1770.72, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1273.8, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 5004.73, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 9081.16, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2390.47, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1719.62, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 9081.16, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Revision of femur epiphysis", "code_information": [ { "code": "27185", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 11375.01, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 20640.13, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 20640.13, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Revision of foot", "code_information": [ { "code": "28116", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2391.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1771.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 8965.53, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 16268.08, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2391.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 16268.08, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Revision of foot bones", "code_information": [ { "code": "28737", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 9484.13, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 7025.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 42267.51, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 76695.09, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 9484.13, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 76695.09, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Revision of foot tendon", "code_information": [ { "code": "28238", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 5265.64, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3900.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 9595.67, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 17434.72, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5265.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 17434.72, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Revision of ileostomy", "code_information": [ { "code": "44312", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2698.5, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1998.89, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 6135.5, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 11133.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2698.5, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 11133.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Revision of iris", "code_information": [ { "code": "66761", "type": "HCPCS" }, { "code": "66762", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 404.37, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 299.54, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 1123.92, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 2039.38, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 404.37, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 2039.38, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Revision of jaw muscle/bone", "code_information": [ { "code": "21296", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2390.47, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1770.72, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 38648.43, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 70128.16, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2390.47, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 70128.16, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Revision of kidney/ureter", "code_information": [ { "code": "50405", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 24472.19, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 44405.22, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 44405.22, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Revision of knee joint", "code_information": [ { "code": "27442", "type": "HCPCS" }, { "code": "27446", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 9484.13, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 7025.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 29799.4, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 54071.49, 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"standard_charge_percentage": 75.0, "estimated_amount": 14408.24, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Revision of pulmonary valve", "code_information": [ { "code": "92990", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 8359.13, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 6191.95, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 24837.94, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 45068.84, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8359.13, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 45068.84, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Revision of radius", "code_information": [ { "code": "25350", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 5265.64, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3900.48, "standard_charge_percentage": 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"additional_payer_notes": "N/A", "standard_charge_dollar": 2775.66, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 7609.76, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 13808.02, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2542.24, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3747.14, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { 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System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 30316.88, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3747.14, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 30316.88, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Revision of thigh muscles", "code_information": [ { "code": "27430", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 5265.64, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare 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49022.47, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Revision of ulna", "code_information": [ { "code": "25360", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 5265.64, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3900.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 20591.24, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 37363.15, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5265.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 37363.15, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Revision of unstable kneecap", "code_information": [ { "code": "27420", "type": "HCPCS" }, { "code": "27422", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 5265.64, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3900.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 23285.5, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 42251.92, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5265.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 42251.92, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Revision of upper eyelid", "code_information": [ { "code": "15822", "type": "HCPCS" }, { "code": "15823", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1348.33, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 998.76, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 6059.23, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 10994.56, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1348.33, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 10994.56, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Revision of urethra", "code_information": [ { "code": "53450", "type": "HCPCS" }, { "code": "53460", "type": "HCPCS" }, { "code": "57220", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 3638.66, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1883.14, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2695.3, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 5436.77, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 9865.11, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2542.24, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3638.66, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 9865.11, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Revision of uterus", "code_information": [ { "code": "58540", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 9553.79, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 17335.51, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 17335.51, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Revision orbitofacial bones", "code_information": [ { "code": "21275", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4360.43, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3229.95, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 54182.04, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 98314.21, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4360.43, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 98314.21, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Revision tips", "code_information": [ { "code": "37183", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4202.59, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3113.03, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 23191.31, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 42081.01, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4202.59, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 42081.01, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Revj peri-implt capsule brst", "code_information": [ { "code": "19370", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2822.56, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2090.79, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 13611.43, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 24698.15, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2822.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 24698.15, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Revj prior hypspad repair", "code_information": [ { "code": "54352", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 3747.14, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2775.66, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 32794.23, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 59505.67, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3747.14, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 59505.67, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Revj reconstructed breast", "code_information": [ { "code": "19380", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4806.97, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3560.72, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 12491.76, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 23238.9, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4806.97, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 23238.9, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Rf abltj nrv nrvtg si jt", "code_information": [ { "code": "64625", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1439.39, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1066.21, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 2710.16, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 4917.63, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1439.39, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 4917.63, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "RHO D IMMUNE GLOBULIN 1500 UNIT/2ML IJ SOSY", "drug_information": { "unit": "2.000000", "type": "UN" }, "code_information": [ { "code": "44206030001", "type": "NDC" } ], "standard_charges": [ { "minimum": 58.92, "maximum": 196.53, "gross_charge": 209.07, "discounted_cash": 114.99, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 121.26, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 114.15, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 167.26, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 177.08, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.84, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 100.35, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 125.23, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 125.02, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 196.53, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 183.98, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 58.92, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 177.71, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 156.8, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 73.66, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 142.17, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 196.53, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 163.7, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 114.15, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 166.21, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 156.8, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 183.98, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 121.26, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 114.15, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "RHO D IMMUNE GLOBULIN 1500 UNITS IM SOSY", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "13533063111", "type": "NDC" } ], "standard_charges": [ { "minimum": 60.46, "maximum": 201.69, "gross_charge": 214.56, "discounted_cash": 118.01, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 124.44, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 117.15, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 171.65, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 181.73, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 62.44, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 102.99, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 128.52, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 128.31, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 201.69, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 188.81, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.46, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 182.38, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 160.92, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.59, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 145.9, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 201.69, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 168.0, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 117.15, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 170.58, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 160.92, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 188.81, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 124.44, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 117.15, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Rib cartilage graft", "code_information": [ { "code": "21230", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4360.43, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3229.95, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 29255.69, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 53084.95, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4360.43, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 53084.95, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "RIBAVIRIN 200 MG PO TABS", "drug_information": { "unit": "2.000000", "type": "UN" }, "code_information": [ { "code": "65862020768", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "RIBAVIRIN 40 MG/ML ORAL SUSPENSION", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "P0085135105", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "RIBAVIRIN 6 G IN SOLR", "drug_information": { "unit": "100.000000", "type": "UN" }, "code_information": [ { "code": "68382039504", "type": "NDC" } ], "standard_charges": [ { "minimum": 8115.84, "maximum": 27072.0, "gross_charge": 28800.0, "discounted_cash": 15840.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 16704.0, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 15724.8, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23040.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 24393.6, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8380.8, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13824.0, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 17251.2, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 11394.0, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 27072.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 25344.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 8115.84, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 24480.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21600.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 10146.24, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 19584.0, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27072.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 22550.4, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 15724.8, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 15189.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21600.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 25344.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 16704.0, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 15724.8, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "RIBOFLAV5 & RIBOFLAV5-DEXTRAN 0.146 &0.146-20 % OP SOSY", "drug_information": { "unit": "6.000000", "type": "UN" }, "code_information": [ { "code": "25357002503", "type": "NDC" } ], "standard_charges": [ { "minimum": 3508.41, "maximum": 11703.0, "gross_charge": 12450.0, "discounted_cash": 6847.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 7221.0, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 6797.7, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9960.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10545.15, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3622.95, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5976.0, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7457.55, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 7445.1, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11703.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10956.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3508.41, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10582.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9337.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 4386.14, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 8466.0, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 11703.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 9748.35, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6797.7, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 9897.75, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9337.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10956.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7221.0, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6797.7, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "RIFABUTIN 150 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "70954004110", "type": "NDC" } ], "standard_charges": [ { "minimum": 4.41, "maximum": 14.71, "gross_charge": 15.65, "discounted_cash": 8.61, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.08, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.54, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.52, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.26, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.55, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.51, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.37, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.36, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.71, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.77, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.41, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.3, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.74, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.51, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.64, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.71, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.25, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.54, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.44, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.74, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.77, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.08, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.54, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "RIFABUTIN 20MG/ML SUSPENSION", "drug_information": { "unit": "7.500000", "type": "UN" }, "code_information": [ { "code": "P0013530117", "type": "NDC" } ], "standard_charges": [ { "minimum": 14.53, "maximum": 48.48, "gross_charge": 51.57, "discounted_cash": 28.36, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.91, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.16, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.26, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.68, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.75, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.84, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 48.48, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.38, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.53, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.83, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.68, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.17, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.07, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 48.48, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.38, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.16, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.68, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.38, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.91, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.16, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "RIFAMPIN 150 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687057521", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.38, "maximum": 4.62, "gross_charge": 4.91, "discounted_cash": 2.7, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.85, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.68, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.93, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.16, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.43, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.36, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.94, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.94, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.62, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.32, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.38, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.68, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.73, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.34, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.62, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.84, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.68, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.9, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.68, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.32, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.85, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.68, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "RIFAMPIN 30 MG/ML SUSPENSION", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "P5155207150", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 1158.0, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.47, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "RIFAMPIN 300 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687058601", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "RIFAMPIN 600 MG IV SOLR", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "67457044560", "type": "NDC" } ], "standard_charges": [ { "minimum": 115.85, "maximum": 1158.0, "gross_charge": 411.11, "discounted_cash": 226.11, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 238.44, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 224.47, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 356.84, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 119.63, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 197.33, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 246.25, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 245.84, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 386.44, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 361.78, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 115.85, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 349.44, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 308.33, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 144.83, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 279.55, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 386.44, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 321.9, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 224.47, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 326.83, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 308.33, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 361.78, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 238.44, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 224.47, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "RIFAPENTINE 150 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00088210224", "type": "NDC" } ], "standard_charges": [ { "minimum": 3.09, "maximum": 10.31, "gross_charge": 10.97, "discounted_cash": 6.03, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.36, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.99, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.78, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.29, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.19, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.27, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.57, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.56, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.31, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.65, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.09, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.32, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.23, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.86, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.46, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.31, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.59, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.99, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.72, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.23, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.65, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.36, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.99, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "RIFAXIMIN 200 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "R6564930103", "type": "NDC" } ], "standard_charges": [ { "minimum": 14.24, "maximum": 47.49, "gross_charge": 50.52, "discounted_cash": 27.79, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.3, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.58, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.42, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.79, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.7, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.25, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.26, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.21, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.49, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 44.46, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.24, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.94, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.89, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.8, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.35, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.49, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.56, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.58, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.16, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.89, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 44.46, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.3, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.58, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "RIFAXIMIN 550 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "65649030303", "type": "NDC" } ], "standard_charges": [ { "minimum": 44.65, "maximum": 148.95, "gross_charge": 158.46, "discounted_cash": 87.15, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 91.91, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.52, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 126.77, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 134.22, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.11, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 76.06, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 94.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 94.76, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 148.95, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 139.44, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 44.65, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 134.69, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 118.85, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.83, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 107.75, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 148.95, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 124.07, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.52, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 125.98, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 118.85, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 139.44, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 91.91, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.52, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "RIFAXIMIN 55MG/ML SUSPENSION", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "R6564930202", "type": "NDC" } ], "standard_charges": [ { "minimum": 21.28, "maximum": 71.0, "gross_charge": 75.53, "discounted_cash": 41.54, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.81, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.24, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.42, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.97, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.98, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.25, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.24, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.17, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 71.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 66.47, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.28, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 64.2, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 56.65, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.61, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 51.36, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 71.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.14, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.24, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.05, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 56.65, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 66.47, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.81, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.24, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Right heart cath", "code_information": [ { "code": "93451", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2370.82, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1756.16, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 9480.87, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 17203.2, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2370.82, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 17203.2, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "RILPIVIRINE HCL 25 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "59676027801", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.55, "maximum": 105.24, "gross_charge": 111.96, "discounted_cash": 61.58, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 64.94, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.13, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 89.57, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 94.83, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.58, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 53.74, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 67.06, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 66.95, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 105.24, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 98.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.55, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 95.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 83.97, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.44, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 76.13, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 105.24, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.66, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.13, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 89.01, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 83.97, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 98.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 64.94, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.13, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "RILUZOLE 50 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "67877028660", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "RIMABOTULINUMTOXINB 10000 UNIT/2ML IM SOLN", "drug_information": { "unit": "2.000000", "type": "UN" }, "code_information": [ { "code": "10454071210", "type": "NDC" } ], "standard_charges": [ { "minimum": 7.09, "maximum": 3511.58, "gross_charge": 3735.72, "discounted_cash": 2054.65, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2166.72, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.09, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2988.58, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3164.15, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1087.09, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1793.15, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2237.7, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2233.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3511.58, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3287.43, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1052.73, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3175.36, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2801.79, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1316.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2540.29, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3511.58, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2925.07, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.57, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2969.9, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2801.79, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3287.43, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2166.72, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.09, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "RIMABOTULINUMTOXINB 2500 UNIT/0.5ML IM SOLN", "drug_information": { "unit": "0.500000", "type": "UN" }, "code_information": [ { "code": "10454071010", "type": "NDC" } ], "standard_charges": [ { "minimum": 7.09, "maximum": 1170.53, "gross_charge": 1245.24, "discounted_cash": 684.88, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 722.24, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.09, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 996.19, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1054.72, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 362.36, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 597.72, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 745.9, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 744.65, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1170.53, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1095.81, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 350.91, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1058.45, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 933.93, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 438.7, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 846.76, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1170.53, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 975.02, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.57, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 989.97, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 933.93, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1095.81, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 722.24, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.09, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "RIMABOTULINUMTOXINB 5000 UNIT/ML IM SOLN", "drug_information": { "unit": "0.500000", "type": "UN" }, "code_information": [ { "code": "10454071110", "type": "NDC" } ], "standard_charges": [ { "minimum": 7.09, "maximum": 2341.05, "gross_charge": 2490.48, "discounted_cash": 1369.76, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1444.48, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.09, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1992.38, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2109.44, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 724.73, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1195.43, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1491.8, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 1489.31, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2341.05, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2191.62, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 701.82, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2116.91, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1867.86, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 877.4, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1693.53, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2341.05, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1950.05, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.57, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1979.93, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1867.86, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2191.62, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1444.48, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.09, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "RIOCIGUAT 0.5 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "50419025091", "type": "NDC" } ], "standard_charges": [ { "minimum": 151.61, "maximum": 505.71, "gross_charge": 537.99, "discounted_cash": 295.89, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 312.03, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 293.74, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 430.39, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 455.68, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 156.56, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 258.24, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 322.26, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 321.72, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 505.71, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 473.43, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 151.61, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 457.29, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 403.49, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 189.53, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 365.83, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 505.71, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 421.25, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 293.74, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 427.7, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 403.49, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 473.43, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 312.03, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 293.74, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "RIOCIGUAT 1 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "50419025191", "type": "NDC" } ], "standard_charges": [ { "minimum": 151.61, "maximum": 505.71, "gross_charge": 537.99, "discounted_cash": 295.89, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 312.03, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 293.74, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 430.39, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 455.68, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 156.56, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 258.24, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 322.26, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 321.72, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 505.71, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 473.43, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 151.61, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 457.29, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 403.49, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 189.53, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 365.83, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 505.71, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 421.25, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 293.74, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 427.7, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 403.49, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 473.43, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 312.03, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 293.74, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "RIOCIGUAT 1.5 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "50419025291", "type": "NDC" } ], "standard_charges": [ { "minimum": 106.88, "maximum": 356.51, "gross_charge": 379.27, "discounted_cash": 208.6, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 219.98, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 207.08, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 303.42, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 321.24, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 110.37, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 182.05, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 227.18, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 226.8, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 356.51, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 333.76, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 106.88, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 322.38, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 284.45, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 133.62, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 257.9, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 356.51, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 296.97, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 207.08, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 301.52, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 284.45, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 333.76, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 219.98, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 207.08, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "RIOCIGUAT 2.5 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "50419025491", "type": "NDC" } ], "standard_charges": [ { "minimum": 106.88, "maximum": 356.51, "gross_charge": 379.27, "discounted_cash": 208.6, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 219.98, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 207.08, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 303.42, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 321.24, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 110.37, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 182.05, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 227.18, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 226.8, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 356.51, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 333.76, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 106.88, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 322.38, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 284.45, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 133.62, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 257.9, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 356.51, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 296.97, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 207.08, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 301.52, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 284.45, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 333.76, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 219.98, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 207.08, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "RISANKIZUMAB-RZAA 600 MG/10ML IV SOLN", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "00074501501", "type": "NDC" } ], "standard_charges": [ { "minimum": 7748.45, "maximum": 25846.51, "gross_charge": 27496.29, "discounted_cash": 15122.96, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 15947.85, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 15012.97, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21997.03, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23289.36, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8001.42, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13198.22, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 16470.28, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 11394.0, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 25846.51, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 24196.74, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 7748.45, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23371.85, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20622.22, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 9686.94, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 18697.48, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 25846.51, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21529.6, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 15012.97, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 15189.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20622.22, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 24196.74, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 15947.85, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 15012.97, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "RISEDRONATE SODIUM 150 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "65862087011", "type": "NDC" } ], "standard_charges": [ { "minimum": 12.06, "maximum": 40.23, "gross_charge": 42.8, "discounted_cash": 23.54, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.82, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.24, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.25, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.45, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.54, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.64, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.59, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.23, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.66, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.06, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.38, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.1, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.08, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.1, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.23, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.51, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.03, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.1, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.66, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.82, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "RISEDRONATE SODIUM 35 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "59762040504", "type": "NDC" } ], "standard_charges": [ { "minimum": 3.78, "maximum": 12.62, "gross_charge": 13.43, "discounted_cash": 7.39, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.79, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.33, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.74, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.38, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.91, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.45, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.04, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.03, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.62, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.82, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.78, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.42, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.07, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.73, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.13, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.62, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.52, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.33, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.68, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.07, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.82, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.79, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.33, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "RISEDRONATE SODIUM 35 MG PO TBEC", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00430097903", "type": "NDC" } ], "standard_charges": [ { "minimum": 51.03, "maximum": 170.21, "gross_charge": 181.07, "discounted_cash": 99.59, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 105.02, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 98.86, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 144.86, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 153.37, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.69, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.91, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 108.46, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 108.28, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 170.21, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 159.34, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 51.03, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 153.91, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 135.8, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.79, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 123.13, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 170.21, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 141.78, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 98.86, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 143.95, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 135.8, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 159.34, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 105.02, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 98.86, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "RISPERIDONE 0.25 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68084027001", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "RISPERIDONE 0.25 MG PO TBDP", "drug_information": { "unit": "2.000000", "type": "UN" }, "code_information": [ { "code": "49884021255", "type": "NDC" } ], "standard_charges": [ { "minimum": 3.34, "maximum": 11.15, "gross_charge": 11.86, "discounted_cash": 6.52, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.88, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.48, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.49, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.05, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.45, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.69, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.1, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.09, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.15, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.44, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.34, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.08, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.9, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.18, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.06, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.15, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.29, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.48, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.43, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.9, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.44, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.88, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.48, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "RISPERIDONE 0.5 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68084027101", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "RISPERIDONE 0.5 MG PO TBDP", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "49884031191", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "RISPERIDONE 1 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68084027201", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "RISPERIDONE 1 MG PO TBDP", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "49884031591", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "RISPERIDONE 1 MG/ML PO SOLN", "drug_information": { "unit": "0.250000", "type": "UN" }, "code_information": [ { "code": "27808000201", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "RISPERIDONE 2 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68084027301", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "RISPERIDONE 2 MG PO TBDP", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "49884040191", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "RISPERIDONE 3 MG PO TBDP", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "49884040291", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "RISPERIDONE MICROSPHERES ER 12.5 MG IM SRER", "drug_information": { "unit": "13.000000", "type": "ME" }, "code_information": [ { "code": "50458030911_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 6.17, "maximum": 2051.16, "gross_charge": 2182.08, "discounted_cash": 1200.14, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1265.61, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.17, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1745.66, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1848.22, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 634.99, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1047.4, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1307.07, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 1304.88, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2051.16, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1920.23, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 614.91, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1854.77, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1636.56, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 768.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1483.81, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2051.16, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1708.57, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.33, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1734.75, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1636.56, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1920.23, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1265.61, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.17, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "RISPERIDONE MICROSPHERES ER 12.5 MG IM SRER|DISCARDED DRUG NOT ADMINISTERED", "drug_information": { "unit": "13.000000", "type": "ME" }, "code_information": [ { "code": "50458030911", "type": "NDC" } ], "standard_charges": [ { "minimum": 6.17, "maximum": 1025.58, "gross_charge": 1091.04, "discounted_cash": 600.07, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 632.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.17, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 872.83, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 924.11, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 317.49, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 523.7, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 653.53, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 652.44, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1025.58, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 960.12, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 307.46, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 927.38, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 818.28, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 384.37, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 741.91, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1025.58, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 854.28, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.33, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 867.38, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 818.28, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 960.12, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 632.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.17, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "RISPERIDONE MICROSPHERES ER 25 MG IM SRER", "drug_information": { "unit": "2.000000", "type": "UN" }, "code_information": [ { "code": "50458030611", "type": "NDC" } ], "standard_charges": [ { "minimum": 6.17, "maximum": 2051.0, "gross_charge": 2181.92, "discounted_cash": 1200.06, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1265.51, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.17, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1745.54, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1848.09, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 634.94, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1047.32, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1306.97, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 1304.79, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2051.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1920.09, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 614.87, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1854.63, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1636.44, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 768.69, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1483.71, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2051.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1708.44, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.33, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1734.63, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1636.44, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1920.09, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1265.51, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.17, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "RISPERIDONE MICROSPHERES ER 37.5 MG IM SRER", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "50458030711", "type": "NDC" } ], "standard_charges": [ { "minimum": 922.33, "maximum": 3076.62, "gross_charge": 3273.0, "discounted_cash": 1800.15, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1898.34, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1787.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2618.4, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2772.23, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 952.44, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1571.04, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1960.53, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 1957.25, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3076.62, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2880.24, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 922.33, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2782.05, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2454.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1153.08, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2225.64, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3076.62, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2562.76, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1787.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2602.04, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2454.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2880.24, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1898.34, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1787.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "RISPERIDONE MICROSPHERES ER 50 MG IM SRER", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "50458030811", "type": "NDC" } ], "standard_charges": [ { "minimum": 922.37, "maximum": 3076.73, "gross_charge": 3273.12, "discounted_cash": 1800.22, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1898.41, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1787.12, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2618.5, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2772.33, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 952.48, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1571.1, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1960.6, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 1957.33, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3076.73, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2880.35, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 922.37, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2782.15, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2454.84, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1153.12, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2225.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3076.73, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2562.85, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1787.12, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2602.13, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2454.84, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2880.35, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1898.41, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1787.12, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "RITONAVIR 100 MG PO PACK", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00074339930", "type": "NDC" } ], "standard_charges": [ { "minimum": 5.47, "maximum": 18.25, "gross_charge": 19.41, "discounted_cash": 10.68, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.26, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.6, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.53, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.44, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.65, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.32, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.63, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.61, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.25, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.08, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.47, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.56, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.84, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.25, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.2, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.6, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.43, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.56, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.08, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.26, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.6, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "RITONAVIR 100 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687042025", "type": "NDC" } ], "standard_charges": [ { "minimum": 4.11, "maximum": 13.72, "gross_charge": 14.6, "discounted_cash": 8.03, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.47, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.97, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.68, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.37, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.25, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.01, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.75, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.73, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.72, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.85, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.11, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.41, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.95, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.14, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.93, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.72, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.43, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.97, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.61, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.95, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.85, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.47, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.97, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "RITUXIMAB (RITUXAN) 1 MG/0.1 ML INTRAVITREAL", "drug_information": { "unit": "0.100000", "type": "UN" }, "code_information": [ { "code": "50242005121", "type": "NDC" } ], "standard_charges": [ { "minimum": 694.85, "maximum": 2317.82, "gross_charge": 2465.77, "discounted_cash": 1356.17, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1430.15, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1346.31, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1972.62, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2088.51, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 717.54, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1183.57, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1477.0, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 1474.53, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2317.82, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2169.88, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 694.85, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2095.9, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1849.33, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 868.69, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1676.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2317.82, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1930.7, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1346.31, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1960.29, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1849.33, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2169.88, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1430.15, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1346.31, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "RITUXIMAB 100 MG/10ML IV SOLN", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "50242005121_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 900.17, "maximum": 3002.7, "gross_charge": 3194.36, "discounted_cash": 1756.9, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1852.73, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1744.12, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2555.49, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2705.62, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", 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"additional_payer_notes": "N/A", "standard_charge_dollar": 2811.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 900.17, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2715.21, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2395.77, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1125.37, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2172.16, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3002.7, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2501.18, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1744.12, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2539.52, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2395.77, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2811.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1852.73, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1744.12, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "RITUXIMAB 500 MG/50ML IV SOLN", "drug_information": { "unit": "50.000000", "type": "UN" }, "code_information": [ { "code": "50242005306", "type": "NDC" } ], "standard_charges": [ { "minimum": 3375.65, "maximum": 11260.15, "gross_charge": 11978.88, "discounted_cash": 6588.38, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 6947.75, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 6540.47, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9583.1, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10146.11, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3485.85, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5749.86, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7175.35, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 7163.37, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11260.15, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10541.41, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3375.65, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10182.05, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8984.16, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 4220.16, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 8145.64, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 11260.15, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 9379.46, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6540.47, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 9523.21, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8984.16, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10541.41, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6947.75, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6540.47, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "RITUXIMAB-ABBS 100 MG/10ML IV SOLN", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "63459010310", "type": "NDC" } ], "standard_charges": [ { "minimum": 18.34, "maximum": 2220.43, "gross_charge": 2362.16, "discounted_cash": 1299.19, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1370.05, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.34, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1889.73, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2000.75, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 687.39, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1133.84, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1414.93, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 1412.57, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2220.43, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2078.7, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 665.66, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2007.84, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1771.62, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 832.19, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1606.27, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2220.43, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1849.57, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.76, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1877.92, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1771.62, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2078.7, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1370.05, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.34, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "RITUXIMAB-ABBS 500 MG/50ML IV SOLN", "drug_information": { "unit": "50.000000", "type": "UN" }, "code_information": [ { "code": "63459010450", "type": "NDC" } ], "standard_charges": [ { "minimum": 18.34, "maximum": 8326.5, "gross_charge": 8857.98, "discounted_cash": 4871.89, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5137.63, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.34, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7086.38, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7502.71, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2577.67, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4251.83, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5305.93, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 5297.07, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8326.5, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7795.02, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2496.18, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7529.28, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6643.49, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3120.67, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6023.43, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 8326.5, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6935.8, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.76, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7042.09, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6643.49, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7795.02, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5137.63, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.34, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "RITUXIMAB-ARRX 100 MG/10ML IV SOLN", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "55513022401", "type": "NDC" } ], "standard_charges": [ { "minimum": 509.44, "maximum": 1699.33, "gross_charge": 1807.8, "discounted_cash": 994.29, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1048.52, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 987.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1446.24, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1531.21, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 526.07, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 867.74, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1082.87, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 1081.06, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1699.33, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1590.86, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 509.44, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1536.63, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1355.85, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 636.89, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1229.3, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1699.33, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1415.51, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 987.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1437.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1355.85, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1590.86, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1048.52, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 987.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "RITUXIMAB-HYALURONIDASE HUMAN 1400-23400 MG -UT/11.7ML SC SOLN", "drug_information": { "unit": "11.700000", "type": "UN" }, "code_information": [ { "code": "50242010801", "type": "NDC" } ], "standard_charges": [ { "minimum": 4725.86, "maximum": 15764.05, "gross_charge": 16770.27, "discounted_cash": 9223.65, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 9726.76, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 9156.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13416.22, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14204.42, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4880.15, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8049.73, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 10045.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 10028.62, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15764.05, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14757.84, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 4725.86, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14254.73, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12577.7, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 5908.17, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 11403.78, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 15764.05, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 13131.12, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 9156.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 13332.36, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12577.7, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14757.84, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 9726.76, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 9156.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "RITUXIMAB-HYALURONIDASE HUMAN 1600-26800 MG -UT/13.4ML SC SOLN", "drug_information": { "unit": "13.400000", "type": "UN" }, "code_information": [ { "code": "50242010901", "type": "NDC" } ], "standard_charges": [ { "minimum": 20.17, "maximum": 18016.08, "gross_charge": 19166.04, "discounted_cash": 10541.32, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 11116.3, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.17, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15332.83, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16233.64, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5577.32, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9199.7, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 11480.46, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 11394.0, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 18016.08, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16866.12, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 5400.99, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16291.13, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14374.53, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 6752.2, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 13032.91, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 18016.08, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 15007.01, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.23, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 15189.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14374.53, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16866.12, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 11116.3, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.17, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "RITUXIMAB-PVVR 100 MG/10ML IV SOLN", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "00069023801", "type": "NDC" } ], "standard_charges": [ { "minimum": 12.25, "maximum": 1986.9, "gross_charge": 2113.72, "discounted_cash": 1162.55, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1225.96, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.25, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1690.98, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1790.32, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 615.09, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1014.59, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1266.12, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 1264.0, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1986.9, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1860.07, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 595.65, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1796.66, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1585.29, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 744.66, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1437.33, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1986.9, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1655.04, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.54, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1680.41, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1585.29, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1860.07, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1225.96, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.25, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "RITUXIMAB-PVVR 500 MG/50ML IV SOLN", "drug_information": { "unit": "50.000000", "type": "UN" }, "code_information": [ { "code": "00069024901", "type": "NDC" } ], "standard_charges": [ { "minimum": 2233.66, "maximum": 7450.81, "gross_charge": 7926.39, "discounted_cash": 4359.51, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4597.31, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4327.81, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6341.11, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6713.65, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2306.58, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3804.67, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4747.91, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4739.98, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7450.81, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6975.22, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2233.66, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6737.43, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5944.79, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2792.47, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5389.95, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7450.81, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6206.36, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4327.81, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6301.48, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5944.79, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6975.22, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4597.31, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4327.81, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "RIVAROXABAN 1 MG/ML PO SUSR", "drug_information": { "unit": "155.000000", "type": "UN" }, "code_information": [ { "code": "50458057501", "type": "NDC" } ], "standard_charges": [ { "minimum": 300.96, "maximum": 1003.9, "gross_charge": 1067.98, "discounted_cash": 587.39, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 619.43, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 583.12, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 854.38, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 904.58, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 310.78, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 512.63, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 639.72, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 638.65, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1003.9, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 939.82, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 300.96, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 907.78, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 800.99, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 376.25, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 726.23, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1003.9, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 836.23, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 583.12, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 849.04, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 800.99, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 939.82, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 619.43, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 583.12, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "RIVAROXABAN 10 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "50458058010", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "RIVAROXABAN 15 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "50458057810", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "RIVAROXABAN 2.5 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "50458057710", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "RIVAROXABAN 20 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "50458057910", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "RIVASTIGMINE 13.3 MG/24HR TD PT24", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "51991089930", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "RIVASTIGMINE 4.6 MG/24HR TD PT24", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00781730431", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.45, "maximum": 4.83, "gross_charge": 5.14, "discounted_cash": 2.83, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.98, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.81, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.11, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.35, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.5, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.47, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.08, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.07, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.83, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.45, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.86, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.81, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.5, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.83, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.02, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.81, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.09, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.86, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.98, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.81, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "RIVASTIGMINE 9.5 MG/24HR TD PT24", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00378907193", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "RIVASTIGMINE TARTRATE 1.5 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687077701", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.26, "maximum": 4.21, "gross_charge": 4.48, "discounted_cash": 2.46, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.45, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.58, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.79, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.3, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.15, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.68, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.68, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.21, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.94, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.26, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.81, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.36, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.58, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.05, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.21, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.51, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.45, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.56, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.36, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.94, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.45, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "RIVASTIGMINE TARTRATE 6 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "62332006660", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "RIZATRIPTAN BENZOATE 10 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "67877026218", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Rmv ntr oi imp sk tc esp<100", "code_information": [ { "code": "69727", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2391.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1771.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 6424.31, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 11657.01, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2391.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 11657.01, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Rmv ntr oi implt skl prq esp", "code_information": [ { "code": "69726", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2391.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1771.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 9167.57, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 16634.7, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2391.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 16634.7, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Rmvl & rplcmt dfb gen 2 lead", "code_information": [ { "code": "33263", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 16545.09, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 12255.62, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 35876.91, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 65099.24, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 16545.09, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 65099.24, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Rmvl & rplcmt dfb gen mlt ld", "code_information": [ { "code": "33264", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 23632.59, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 17505.62, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 45558.62, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 82666.85, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23632.59, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 82666.85, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Rmvl b1 flp/prostc plate skl", "code_information": [ { "code": "62142", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 16379.03, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 29766.83, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 29766.83, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Rmvl ext fixj sys under anes", "code_information": [ { "code": "20694", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1179.66, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 873.82, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 25980.09, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 47141.3, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1179.66, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 47141.3, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Rmvl fb upper arm/elbw deep", "code_information": [ { "code": "24201", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2109.62, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 7032.7, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 12760.96, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2109.62, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 12760.96, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Rmvl hpglsl nstim ary pg", "code_information": [ { "code": "64584", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4720.44, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3496.62, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 12349.98, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 22576.07, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4720.44, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 22576.07, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Rmvl intact breast implant", "code_information": [ { "code": "19328", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2822.56, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2090.79, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 18742.81, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 34009.16, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2822.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 34009.16, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Rmvl of subq defibrillator", "code_information": [ { "code": "33272", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2682.53, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1987.06, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 27627.17, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 50129.94, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2682.53, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 50129.94, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Rmvl ruptured breast implant", "code_information": [ { "code": "19330", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2822.56, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2090.79, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 18662.8, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 33863.95, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2822.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 33863.95, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Rmvl subq car rhythm mntr", "code_information": [ { "code": "33286", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 518.62, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 384.16, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 7578.88, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 13755.6, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 518.62, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 13755.6, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Rmvl tis xpndr wo insj implt", "code_information": [ { "code": "11971", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2109.62, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1562.68, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 8915.04, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 16176.5, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2109.62, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 16176.5, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Rmvl& replc pulse gen 1 lead", "code_information": [ { "code": "33262", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 16545.09, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 12255.62, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 34099.17, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 61873.52, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 16545.09, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 61873.52, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ROCURONIUM BROMIDE 10 MG/ML 10 ML DRIP SYRINGE (STRAIGHT DRUG)", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "08252099912", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 1158.0, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.72, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ROCURONIUM BROMIDE 10 MG/ML 100 ML DRIP (STRAIGHT DRUG)", "drug_information": { "unit": "100.000000", "type": "UN" }, "code_information": [ { "code": "08252099915", "type": "NDC" } ], "standard_charges": [ { "minimum": 33.64, "maximum": 1158.0, "gross_charge": 119.36, "discounted_cash": 65.65, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 69.23, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.17, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.6, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.73, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 57.29, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 71.5, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 71.38, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 112.2, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 105.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.64, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 101.46, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 89.52, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.05, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 81.16, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 112.2, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.46, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.17, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 94.89, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 89.52, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 105.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 69.23, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.17, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ROCURONIUM BROMIDE 10 MG/ML 25 ML DRIP SYRINGE (STRAIGHT DRUG)", "drug_information": { "unit": "25.000000", "type": "UN" }, "code_information": [ { "code": "08252099913", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 1158.0, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.72, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ROCURONIUM BROMIDE 10 MG/ML 50 ML DRIP SYRINGE (STRAIGHT DRUG)", "drug_information": { "unit": "50.000000", "type": "UN" }, "code_information": [ { "code": "08252099914", "type": "NDC" } ], "standard_charges": [ { "minimum": 16.82, "maximum": 1158.0, "gross_charge": 59.68, "discounted_cash": 32.82, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.61, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.59, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 51.8, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.37, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.65, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.75, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.69, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 56.1, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.82, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.73, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 44.76, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.03, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.58, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 56.1, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.73, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.59, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 44.76, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.61, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.59, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ROCURONIUM BROMIDE 100 MG/10ML IV SOLN", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "67457022810", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 1158.0, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.72, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ROCURONIUM BROMIDE 100 MG/10ML IV SOSY", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "70092248046", "type": "NDC" } ], "standard_charges": [ { "minimum": 12.44, "maximum": 1158.0, "gross_charge": 44.15, "discounted_cash": 24.28, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.61, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.11, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.32, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.85, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.19, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.45, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.5, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.85, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.44, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.53, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.11, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.55, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.02, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.5, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.57, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.11, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.1, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.11, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.85, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.61, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.11, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ROCURONIUM BROMIDE 50 MG/5ML IV SOLN", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "39822420002", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 1158.0, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.72, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ROCURONIUM BROMIDE 50 MG/5ML IV SOSY", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "70092245244", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ROFLUMILAST 500 MCG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68382096906", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ROMIDEPSIN 10 MG IV SOLR", "drug_information": { "unit": "2.000000", "type": "UN" }, "code_information": [ { "code": "59572098401", "type": "NDC" } ], "standard_charges": [ { "minimum": 16.3, "maximum": 8169.6, "gross_charge": 8691.06, "discounted_cash": 4780.08, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5040.81, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.3, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6952.85, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7361.33, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2529.1, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4171.71, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5205.94, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 5197.25, "standard_charge_percentage": 60.0, "methodology": "percent of total billed 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"standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3061.86, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5909.92, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 8169.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6805.1, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": 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"payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.3, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "ROMIPLOSTIM 250 MCG SC SOLR (125 MCG/ML)", "drug_information": { "unit": "2.000000", "type": "UN" }, "code_information": [ { "code": "55513022101", "type": "NDC" } ], "standard_charges": [ { "minimum": 5.52, "maximum": 7393.81, "gross_charge": 7865.76, "discounted_cash": 4326.17, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4562.14, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.52, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6292.61, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6662.3, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2288.94, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3775.56, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4711.59, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4703.72, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7393.81, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6921.87, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2216.57, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6685.9, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5899.32, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2771.11, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5348.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7393.81, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6158.89, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.45, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6253.28, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5899.32, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6921.87, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4562.14, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.52, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "ROMIPLOSTIM 250 MCG SC SOLR (500 MCG/ML)", "drug_information": { "unit": "0.500000", "type": "UN" }, "code_information": [ { "code": "55513022101_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 5.52, "maximum": 7393.81, "gross_charge": 7865.76, "discounted_cash": 4326.17, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4562.14, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.52, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6292.61, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6662.3, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2288.94, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3775.56, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4711.59, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4703.72, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7393.81, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6921.87, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2216.57, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6685.9, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5899.32, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2771.11, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5348.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7393.81, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6158.89, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.45, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6253.28, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5899.32, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6921.87, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4562.14, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.52, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "ROMOSOZUMAB-AQQG 105 MG/1.17ML SC SOSY", "drug_information": { "unit": "2.340000", "type": "UN" }, "code_information": [ { "code": "55513099802", "type": "NDC" } ], "standard_charges": [ { "minimum": 6.1, "maximum": 7060.55, "gross_charge": 7511.22, "discounted_cash": 4131.17, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4356.51, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.1, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6008.98, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6362.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2185.77, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3605.39, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4499.22, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4491.71, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7060.55, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6609.87, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2116.66, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6384.54, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5633.42, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2646.2, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5107.63, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7060.55, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5881.29, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.23, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5971.42, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5633.42, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6609.87, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4356.51, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.1, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "ROPINIROLE HCL 0.25 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00904637361", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ROPINIROLE HCL 0.5 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "50268074215", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ROPINIROLE HCL 1 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00904637461", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ROPINIROLE HCL 2 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "1013567601", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ROPIV-EPI-CLONIDINE-KETOROLAC 123-0.25-0.04- 15 MG/50ML PA SOSY", "drug_information": { "unit": "50.000000", "type": "UN" }, "code_information": [ { "code": "70092143350", "type": "NDC" } ], "standard_charges": [ { "minimum": 30.25, "maximum": 100.91, "gross_charge": 107.35, "discounted_cash": 59.04, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 62.26, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 58.61, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 85.88, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 90.93, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.24, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 51.53, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 64.3, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 64.2, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 100.91, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 94.47, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.25, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 91.25, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 80.51, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.82, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 73.0, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 100.91, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 84.06, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 58.61, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 85.34, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 80.51, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 94.47, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 62.26, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 58.61, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ROPIVACAINE 0.5% 5 MG/ML 30 ML (BULK CHARGE)", "drug_information": { "unit": "30.000000", "type": "UN" }, "code_information": [ { "code": "70069006401", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ROPIVACAINE HCL 10 MG/ML IJ SOLN", "drug_information": { "unit": "20.000000", "type": "UN" }, "code_information": [ { "code": "63323028821", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ROPIVACAINE HCL 2 MG/ML IJ SOLN", "drug_information": { "unit": "20.000000", "type": "UN" }, "code_information": [ { "code": "70069006225", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ROPIVACAINE HCL 2 MG/ML IN NACL ON-Q SOLN (MULTI-GPI)", "drug_information": { "unit": "545.000000", "type": "UN" }, "code_information": [ { "code": "71449007951", "type": "NDC" } ], "standard_charges": [ { "minimum": 93.7, "maximum": 312.55, "gross_charge": 332.5, "discounted_cash": 182.88, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 192.85, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 181.55, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 266.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 281.63, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.76, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 159.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 199.17, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 198.84, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 312.55, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 292.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.7, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 282.63, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 249.38, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 117.14, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 226.1, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 312.55, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 260.35, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 181.55, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 264.34, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 249.38, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 292.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 192.85, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 181.55, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ROPIVACAINE HCL 5 MG/ML IJ SOLN", "drug_information": { "unit": "30.000000", "type": "UN" }, "code_information": [ { "code": "70069006401_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ROPIVACAINE HCL 7.5 MG/ML IJ SOLN", "drug_information": { "unit": "20.000000", "type": "UN" }, "code_information": [ { "code": "63323028720", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ROPIVACAINE HCL-NACL 0.2-0.9 % IJ SOLN (AMBIT PCA PUMP ONLY)", "drug_information": { "unit": "500.000000", "type": "UN" }, "code_information": [ { "code": "73177010926", "type": "NDC" } ], "standard_charges": [ { "minimum": 72.56, "maximum": 242.05, "gross_charge": 257.5, "discounted_cash": 141.63, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 149.35, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 140.6, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 206.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 218.1, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.93, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 123.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 154.24, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 153.99, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 242.05, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 226.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 72.56, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 218.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 193.13, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 90.72, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 175.1, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 242.05, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 201.62, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 140.6, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 204.71, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 193.13, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 226.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 149.35, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 140.6, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ROPIVACAINE HCL-NACL 0.2-0.9 % IJ SOLN (AMBIT PIB PUMP ONLY)", "drug_information": { "unit": "500.000000", "type": "UN" }, "code_information": [ { "code": "73177010926_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 72.56, "maximum": 242.05, "gross_charge": 257.5, "discounted_cash": 141.63, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 149.35, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 140.6, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 206.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 218.1, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.93, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 123.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 154.24, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 153.99, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 242.05, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 226.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 72.56, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 218.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 193.13, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 90.72, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 175.1, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 242.05, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 201.62, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 140.6, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 204.71, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 193.13, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 226.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 149.35, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 140.6, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ROSE BENGAL 1.3 MG OP STRP", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "51801000440", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ROSUVASTATIN CALCIUM 10 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687024501", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ROSUVASTATIN CALCIUM 20 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687025601", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ROSUVASTATIN CALCIUM 40 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "50268071115", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ROSUVASTATIN CALCIUM 5 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687023401", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ROTAVIRUS VAC LIVE PENTAVALENT PO SOLN", "drug_information": { "unit": "2.000000", "type": "UN" }, "code_information": [ { "code": "00006404741", "type": "NDC" } ], "standard_charges": [ { "minimum": 56.22, "maximum": 187.53, "gross_charge": 199.5, "discounted_cash": 109.73, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 115.71, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 108.93, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 159.6, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 168.98, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 58.05, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 95.76, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 119.5, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 119.3, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 187.53, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 175.56, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 56.22, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 169.58, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 149.63, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 70.28, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 135.66, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 187.53, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 156.21, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 108.93, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 158.6, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 149.63, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 175.56, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 115.71, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 108.93, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ROTAVIRUS VACCINE LIVE ORAL PO SUSP", "drug_information": { "unit": "1.500000", "type": "UN" }, "code_information": [ { "code": "58160074021", "type": "NDC" } ], "standard_charges": [ { "minimum": 84.83, "maximum": 282.97, "gross_charge": 301.03, "discounted_cash": 165.57, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 174.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 164.36, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 240.82, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 254.97, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.6, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 144.49, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 180.32, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 180.02, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 282.97, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 264.91, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 84.83, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 255.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 225.77, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 106.05, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 204.7, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 282.97, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 235.71, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 164.36, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 239.32, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 225.77, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 264.91, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 174.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 164.36, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ROTIGOTINE 4 MG/24HR TD PT24", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "50474080403", "type": "NDC" } ], "standard_charges": [ { "minimum": 17.93, "maximum": 59.8, "gross_charge": 63.62, "discounted_cash": 34.99, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.9, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.74, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.9, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 53.89, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.51, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.54, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.11, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.04, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.99, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.93, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.08, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.72, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.26, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.81, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.74, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.58, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.72, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.99, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.9, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.74, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ROTIGOTINE 8 MG/24HR TD PT24", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "50474080603", "type": "NDC" } ], "standard_charges": [ { "minimum": 17.93, "maximum": 59.8, "gross_charge": 63.62, "discounted_cash": 34.99, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.9, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.74, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.9, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 53.89, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.51, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.54, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.11, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.04, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.99, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.93, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.08, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.72, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.26, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.81, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.74, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.58, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.72, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.99, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.9, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.74, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Rpl b1 flp/prostc plate skl", "code_information": [ { "code": "62143", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 37197.51, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 68164.43, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 68164.43, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Rplc gtube no revj trc", "code_information": [ { "code": "43762", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 179.27, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 570.4, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 1035.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 179.27, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 1035.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Rplc gtube revj gstrst trc", "code_information": [ { "code": "43763", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 179.27, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 132.79, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 8146.82, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 14782.53, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 179.27, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 14782.53, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Rplcmt oi implt skl prq esp", "code_information": [ { "code": "69717", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 5265.64, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3900.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 32922.96, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 59739.22, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5265.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 59739.22, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Rplcmt tiss xpndr perm implt", "code_information": [ { "code": "11970", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 5265.64, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3900.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 13535.65, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 24560.66, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5265.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 24560.66, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Rpr aa hrn 1st < 3 cm rdc", "code_information": [ { "code": "49591", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2601.27, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1926.87, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 9316.66, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 16905.22, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2601.27, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 16905.22, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Rpr aa hrn 1st < 3 ncr/strn", "code_information": [ { "code": "49592", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4300.51, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3185.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 10004.39, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 18387.14, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4300.51, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 18387.14, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Rpr aa hrn 1st > 10 ncr/strn", "code_information": [ { "code": "49596", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 34273.45, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 62189.74, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 62189.74, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Rpr aa hrn 1st > 10 rdc", "code_information": [ { "code": "49595", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4599.32, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3406.9, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 25023.49, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 45405.52, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4599.32, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 45405.52, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Rpr aa hrn 1st 3-10 ncr/strn", "code_information": [ { "code": "49594", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4300.51, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3185.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 12988.05, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 23567.02, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4300.51, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 23567.02, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Rpr aa hrn 1st 3-10 rdc", "code_information": [ { "code": "49593", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4599.32, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3406.9, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 9429.74, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 17348.02, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4599.32, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 17348.02, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Rpr aa hrn rcr < 3 ncr/strn", "code_information": [ { "code": "49614", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4300.51, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3185.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 16612.57, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 30143.92, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4300.51, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 30143.92, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Rpr aa hrn rcr < 3 rdc", "code_information": [ { "code": "49613", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2601.27, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1926.87, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 8629.98, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 15659.24, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2601.27, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 15659.24, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Rpr aa hrn rcr > 10 ncr/strn", "code_information": [ { "code": "49618", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 26978.19, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 48952.41, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 48952.41, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Rpr aa hrn rcr > 10 rdc", "code_information": [ { "code": "49617", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 34994.09, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 63497.4, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 63497.4, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Rpr aa hrn rcr 3-10 ncr/strn", "code_information": [ { "code": "49616", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 21765.3, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 39493.51, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 39493.51, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Rpr aa hrn rcr 3-10 rdc", "code_information": [ { "code": "49615", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4599.32, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3406.9, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 10170.57, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 18454.69, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4599.32, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 18454.69, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Rpr fem hernia init blocked", "code_information": [ { "code": "49553", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2601.27, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1926.87, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 14383.86, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 26099.73, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2601.27, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 26099.73, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Rpr hern preemie reduc", "code_information": [ { "code": "49491", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4300.51, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3185.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 8382.77, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 15210.65, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4300.51, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 15210.65, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Rpr ing hernia baby blocked", "code_information": [ { "code": "49496", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2601.27, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1926.87, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 12479.36, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 22644.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2601.27, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 22644.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Rpr ing hernia baby reduc", "code_information": [ { "code": "49495", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2601.27, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1926.87, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 8606.13, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 15615.96, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2601.27, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 15615.96, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Rpr ing hernia init reduce", "code_information": [ { "code": "49500", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4599.32, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3406.9, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 11421.51, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 20724.51, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4599.32, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 20724.51, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Rpr nsl vlv collapse w/implt", "code_information": [ { "code": "30468", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4360.43, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3229.95, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 15696.81, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 28482.13, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4360.43, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 28482.13, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Rpr nsl vlv collapse w/rmdlg", "code_information": [ { "code": "30469", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4360.43, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3229.95, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 10838.44, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 19666.51, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4360.43, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 19666.51, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Rpr parastomal hernia rdc", "code_information": [ { "code": "49621", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 19798.33, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 36216.58, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 36216.58, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Rpr rem hernia init reduce", "code_information": [ { "code": "49550", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2601.27, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1926.87, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 6629.64, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 12029.58, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2601.27, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 12029.58, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Rpr tdn/musc upr a/e each", "code_information": [ { "code": "24341", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 5265.64, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3900.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 16240.06, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 29467.87, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5265.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 29467.87, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Rrp hypspad comp moblj&urtp", "code_information": [ { "code": "54344", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 6816.07, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5048.94, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 19835.03, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 36304.78, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6816.07, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 36304.78, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "RSV PRE-FUSION F A&B VAC RCMB 120 MCG/0.5ML IM SOLR", "drug_information": { "unit": "0.500000", "type": "UN" }, "code_information": [ { "code": "00069034405", "type": "NDC" } ], "standard_charges": [ { "minimum": 231.9, "maximum": 773.54, "gross_charge": 822.92, "discounted_cash": 452.61, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 477.29, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 449.31, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 658.34, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 697.01, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 239.47, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 395.0, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 492.93, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 492.11, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 773.54, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 724.17, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 231.9, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 699.48, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 617.19, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 289.91, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 559.59, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 773.54, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 644.35, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 449.31, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 654.22, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 617.19, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 724.17, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 477.29, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 449.31, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "RSVPREF3 VAC RECOMB ADJUVANTED 120 MCG/0.5ML IM SUSR", "drug_information": { "unit": "0.500000", "type": "UN" }, "code_information": [ { "code": "58160084811", "type": "NDC" } ], "standard_charges": [ { "minimum": 233.74, "maximum": 779.68, "gross_charge": 829.45, "discounted_cash": 456.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 481.08, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 452.88, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 663.56, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 702.54, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 241.37, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 398.14, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 496.84, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 496.01, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 779.68, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 729.92, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 233.74, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 705.03, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 622.09, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 292.22, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 564.03, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 779.68, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 649.46, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 452.88, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 659.41, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 622.09, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 729.92, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 481.08, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 452.88, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "RUBIDIUM RB 82 CHLORIDE IV SOLR", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00270009101", "type": "NDC" } ], "standard_charges": [ { "minimum": 806.76, "maximum": 2691.1, "gross_charge": 2862.87, "discounted_cash": 1574.58, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1660.46, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1563.13, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2290.3, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2424.85, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 833.1, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1374.18, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1714.86, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 1712.0, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2691.1, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2519.33, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 806.76, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2433.44, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2147.15, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1008.59, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1946.75, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2691.1, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2241.63, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1563.13, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2275.98, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2147.15, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2519.33, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1660.46, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1563.13, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "RUFINAMIDE 200 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00378233078", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.65, "maximum": 5.52, "gross_charge": 5.87, "discounted_cash": 3.23, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.21, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.7, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.97, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.71, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.82, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.51, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.17, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.65, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.99, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.4, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.07, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.99, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.6, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.21, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.67, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.4, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.17, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.21, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "RUFINAMIDE 40 MG/ML PO SUSP", "drug_information": { "unit": "460.000000", "type": "UN" }, "code_information": [ { "code": "69452022384", "type": "NDC" } ], "standard_charges": [ { "minimum": 239.28, "maximum": 798.15, "gross_charge": 849.1, "discounted_cash": 467.01, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 492.48, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 463.61, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 679.28, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 719.19, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 247.09, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 407.57, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 508.61, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 507.76, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 798.15, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 747.21, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 239.28, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 721.74, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 636.83, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 299.14, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 577.39, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 798.15, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 664.85, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 463.61, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 675.03, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 636.83, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 747.21, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 492.48, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 463.61, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "RUFINAMIDE 400 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68462071408", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SACCHAROMYCES BOULARDII 250 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "04142000007", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SACITUZUMAB GOVITECAN-HZIY 180 MG IV SOLR", "drug_information": { "unit": "18.000000", "type": "UN" }, "code_information": [ { "code": "55135013201", "type": "NDC" } ], "standard_charges": [ { "minimum": 2083.03, "maximum": 6948.37, "gross_charge": 7391.88, "discounted_cash": 4065.53, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4287.29, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4035.97, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5913.5, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6260.92, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2151.04, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3548.1, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4427.74, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4420.34, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6948.37, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6504.85, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2083.03, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6283.1, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5543.91, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2604.16, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5026.48, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6948.37, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5787.84, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4035.97, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5876.54, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5543.91, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6504.85, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4287.29, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4035.97, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SACUBITRIL-VALSARTAN 4 MG/ML PO SUSP", "drug_information": { "unit": "25.000000", "type": "UN" }, "code_information": [ { "code": "08252000050", "type": "NDC" } ], "standard_charges": [ { "minimum": 7.23, "maximum": 24.1, "gross_charge": 25.64, "discounted_cash": 14.1, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.87, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.0, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.51, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.72, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.46, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.31, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.36, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.33, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.1, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.56, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.23, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.79, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.23, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.03, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.44, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.1, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.08, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.0, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.38, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.23, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.56, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.87, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.0, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SACUBITRIL-VALSARTAN 49-51 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00078077720", "type": "NDC" } ], "standard_charges": [ { "minimum": 7.25, "maximum": 24.17, "gross_charge": 25.71, "discounted_cash": 14.14, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.91, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.04, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.57, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.78, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.48, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.34, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.37, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.17, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.62, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.25, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.85, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.28, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.06, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.48, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.17, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.04, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.44, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.28, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.62, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.91, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.04, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SACUBITRIL-VALSARTAN 97-103 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00078069620", "type": "NDC" } ], "standard_charges": [ { "minimum": 7.25, "maximum": 24.17, "gross_charge": 25.71, "discounted_cash": 14.14, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.91, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.04, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.57, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.78, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.48, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.34, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.37, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.17, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.62, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.25, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.85, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.28, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.06, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.48, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.17, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.04, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.44, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.28, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.62, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.91, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.04, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SALICYLIC ACID 17 % EX LIQD", "drug_information": { "unit": "9.000000", "type": "UN" }, "code_information": [ { "code": "46122036229", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.27, "maximum": 4.23, "gross_charge": 4.5, "discounted_cash": 2.48, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.61, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.46, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.6, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.81, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.31, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.16, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.7, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.69, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.23, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.96, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.83, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.38, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.59, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.06, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.23, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.46, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.58, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.38, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.96, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.61, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.46, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SALICYLIC ACID 6 % EX FOAM", "drug_information": { "unit": "200.000000", "type": "GR" }, "code_information": [ { "code": "23710000602", "type": "NDC" } ], "standard_charges": [ { "minimum": 276.44, "maximum": 922.12, "gross_charge": 980.98, "discounted_cash": 539.54, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 568.97, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 535.62, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 784.78, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 830.89, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 285.47, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 470.87, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 587.61, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 586.63, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 922.12, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 863.26, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 276.44, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 833.83, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 735.74, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 345.6, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 667.07, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 922.12, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 768.11, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 535.62, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 779.88, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 735.74, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 863.26, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 568.97, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 535.62, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SALICYLIC ACID-SULFUR 2-2 % EX SHAM", "drug_information": { "unit": "118.000000", "type": "UN" }, "code_information": [ { "code": "00536196297", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.14, "maximum": 3.81, "gross_charge": 4.05, "discounted_cash": 2.23, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.35, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.21, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.24, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.43, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.18, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.94, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.43, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.42, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.81, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.56, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.14, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.44, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.04, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.43, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.75, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.81, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.17, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.21, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.22, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.04, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.56, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.35, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.21, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SALINE NASAL SPRAY 0.65 % NA SOLN", "drug_information": { "unit": "44.000000", "type": "UN" }, "code_information": [ { "code": "00904386575", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SALINE SPRAY 0.65 % NA SOLN", "drug_information": { "unit": "44.000000", "type": "UN" }, "code_information": [ { "code": "00904386575_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SALMETEROL XINAFOATE 50 MCG/ACT IN AEPB", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00173052100", "type": "NDC" } ], "standard_charges": [ { "minimum": 270.19, "maximum": 901.27, "gross_charge": 958.8, "discounted_cash": 527.34, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 556.1, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 523.5, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 767.04, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 812.1, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 279.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 460.22, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 574.32, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 573.36, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 901.27, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 843.74, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 270.19, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 814.98, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 719.1, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 337.79, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 651.98, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 901.27, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 750.74, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 523.5, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 762.25, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 719.1, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 843.74, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 556.1, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 523.5, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SALSALATE 500 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "51293061501", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SAMARIUM SM 153 LEXIDRONAM 1850 MBQ/ML IV SOLN", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "11994001601", "type": "NDC" } ], "standard_charges": [ { "minimum": 2355.94, "maximum": 50509.47, "gross_charge": 53733.48, "discounted_cash": 29553.41, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 31165.42, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2355.94, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42986.78, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 45512.26, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15636.44, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 25792.07, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 32186.35, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 11394.0, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 50509.47, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 47285.46, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 15142.09, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 45673.46, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 40300.11, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 18930.31, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 36538.77, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 50509.47, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 42073.31, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3180.52, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 15189.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 40300.11, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 47285.46, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31165.42, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2355.94, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "SARGRAMOSTIM 250 MCG IJ SOLR", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "71837584305", "type": "NDC" } ], "standard_charges": [ { "minimum": 32.91, "maximum": 1136.6, "gross_charge": 1209.15, "discounted_cash": 665.03, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 701.31, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.91, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 967.32, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1024.15, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 351.86, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 580.39, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 724.28, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 723.07, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1136.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1064.05, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 340.74, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1027.78, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 906.86, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 425.98, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 822.22, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1136.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 946.76, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 44.43, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 961.27, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 906.86, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1064.05, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 701.31, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.91, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "SARGRAMOSTIM 250 MCG NEBULIZER SOLUTION", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "08252000176", "type": "NDC" } ], "standard_charges": [ { "minimum": 245.65, "maximum": 819.4, "gross_charge": 871.7, "discounted_cash": 479.44, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 505.59, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 475.95, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 697.36, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 738.33, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 253.66, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 418.42, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 522.15, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 521.28, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 819.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 767.1, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 245.65, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 740.95, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 653.78, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 307.1, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 592.76, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 819.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 682.54, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 475.95, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 693.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 653.78, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 767.1, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 505.59, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 475.95, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SARGRAMOSTIM 5 MCG/ML TOPICAL SYRINGE", "drug_information": { "unit": "50.000000", "type": "UN" }, "code_information": [ { "code": "99888000013", "type": "NDC" } ], "standard_charges": [ { "minimum": 245.65, "maximum": 819.4, "gross_charge": 871.7, "discounted_cash": 479.44, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 505.59, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 475.95, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 697.36, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 738.33, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 253.66, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 418.42, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 522.15, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 521.28, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 819.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 767.1, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 245.65, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 740.95, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 653.78, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 307.1, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 592.76, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 819.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 682.54, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 475.95, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 693.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 653.78, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 767.1, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 505.59, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 475.95, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SARILUMAB 200 MG/1.14ML SC SOSY", "drug_information": { "unit": "1.140000", "type": "UN" }, "code_information": [ { "code": "00024591001", "type": "NDC" } ], "standard_charges": [ { "minimum": 1780.76, "maximum": 5940.1, "gross_charge": 6319.25, "discounted_cash": 3475.59, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3665.17, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3450.31, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5055.4, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5352.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1838.9, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3033.24, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3785.23, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 3778.91, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5940.1, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5560.94, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1780.76, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5371.36, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4739.44, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2226.27, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4297.09, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5940.1, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4947.97, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3450.31, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5023.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4739.44, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5560.94, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3665.17, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3450.31, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Sclerotx fluid collection", "code_information": [ { "code": "49185", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1194.28, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 884.65, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 7413.38, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 13451.7, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1194.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 13451.7, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Scope plantar fasciotomy", "code_information": [ { "code": "29893", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2391.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1771.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 7673.12, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 13923.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2391.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 13923.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SCOPOLAMINE 1.5 MG (DELIVERS 1 MG OVER 3 DAYS) PATCH", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "45802058046", "type": "NDC" } ], "standard_charges": [ { "minimum": 4.22, "maximum": 14.08, "gross_charge": 14.98, "discounted_cash": 8.24, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.69, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.98, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.69, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.36, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.19, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.97, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.08, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.18, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.22, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.73, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.24, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.28, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.19, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.08, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.73, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.91, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.24, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.18, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.69, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Sec clsr surg wnd/dehsn xtn", "code_information": [ { "code": "13160", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1348.33, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 998.76, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 9936.36, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 18029.7, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1348.33, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 18029.7, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SECRETIN ACETATE (HUMAN) 16 MCG IV SOLR", "drug_information": { "unit": "8.000000", "type": "UN" }, "code_information": [ { "code": "67066000501", "type": "NDC" } ], "standard_charges": [ { "minimum": 23.24, "maximum": 2416.18, "gross_charge": 2570.4, "discounted_cash": 1413.72, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1490.83, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.24, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2056.32, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2177.13, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 747.99, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1233.79, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1539.67, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 1537.1, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2416.18, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2261.95, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 724.34, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2184.84, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1927.8, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 905.55, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1747.87, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2416.18, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2012.62, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.38, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2043.47, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1927.8, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2261.95, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1490.83, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.24, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "SELEGILINE 12 MG/24HR TD PT24", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "49502090230", "type": "NDC" } ], "standard_charges": [ { "minimum": 54.75, "maximum": 182.61, "gross_charge": 194.27, "discounted_cash": 106.85, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 112.68, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 106.07, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 155.42, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 164.55, "standard_charge_percentage": 85.0, "methodology": 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"standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 170.96, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.75, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 165.13, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 145.7, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 68.44, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 132.1, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 182.61, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 152.11, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 106.07, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 154.44, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 145.7, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 170.96, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 112.68, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 106.07, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SELEGILINE 6 MG/24HR TD PT24", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "49502090030", "type": "NDC" } ], "standard_charges": [ { "minimum": 54.75, "maximum": 182.61, "gross_charge": 194.27, "discounted_cash": 106.85, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 112.68, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 106.07, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 155.42, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 164.55, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 56.53, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.25, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 116.37, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 116.17, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 182.61, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 170.96, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.75, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 165.13, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 145.7, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 68.44, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 132.1, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 182.61, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 152.11, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 106.07, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 154.44, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 145.7, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 170.96, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 112.68, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 106.07, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SELEGILINE 9 MG/24HR TD PT24", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "49502090130", "type": "NDC" } ], "standard_charges": [ { "minimum": 54.75, "maximum": 182.61, "gross_charge": 194.27, "discounted_cash": 106.85, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 112.68, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 106.07, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 155.42, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 164.55, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 56.53, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.25, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 116.37, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 116.17, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 182.61, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 170.96, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.75, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 165.13, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 145.7, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 68.44, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 132.1, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 182.61, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 152.11, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 106.07, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 154.44, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 145.7, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 170.96, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 112.68, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 106.07, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SELEGILINE HCL 5 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60505343803", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SELENIUM 10 MCG/ML ORAL SOLUTION", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "P0517651025", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SELENIUM SULFIDE 1 % EX LOTN", "drug_information": { "unit": "207.000000", "type": "UN" }, "code_information": [ { "code": "00536199553", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.57, "maximum": 5.25, "gross_charge": 5.58, "discounted_cash": 3.07, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.24, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.05, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.46, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.73, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.62, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.68, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.34, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.34, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.25, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.91, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.57, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.74, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.19, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.97, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.79, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.25, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.05, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.44, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.19, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.91, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.24, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.05, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SELENIUM SULFIDE 2.5 % EX LOTN", "drug_information": { "unit": "120.000000", "type": "UN" }, "code_information": [ { "code": "45802004064", "type": "NDC" } ], "standard_charges": [ { "minimum": 4.36, "maximum": 14.55, "gross_charge": 15.48, "discounted_cash": 8.51, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.98, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.45, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.38, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.11, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.5, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.43, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.27, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.26, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.55, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.62, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.36, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.16, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.61, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.45, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.53, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.55, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.12, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.45, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.31, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.61, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.62, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.98, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.45, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SELEXIPAG 200 MCG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "66215060206", "type": "NDC" } ], "standard_charges": [ { "minimum": 213.43, "maximum": 711.93, "gross_charge": 757.37, "discounted_cash": 416.55, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 439.27, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 413.52, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 605.9, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 641.49, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 220.39, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 363.54, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 453.66, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 452.91, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 711.93, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 666.49, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 213.43, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 643.76, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 568.03, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 266.82, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 515.01, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 711.93, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 593.02, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 413.52, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 602.11, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 568.03, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 666.49, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 439.27, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 413.52, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SELEXIPAG 600 MCG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "66215060606", "type": "NDC" } ], "standard_charges": [ { "minimum": 379.33, "maximum": 1265.32, "gross_charge": 1346.09, "discounted_cash": 740.35, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 780.73, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 734.97, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1076.87, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1140.14, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 391.71, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 646.12, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 806.31, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 804.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1265.32, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1184.56, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 379.33, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1144.18, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1009.57, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 474.23, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 915.34, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1265.32, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1053.99, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 734.97, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1070.14, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1009.57, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1184.56, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 780.73, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 734.97, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SELEXIPAG 800 MCG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "66215060806", "type": "NDC" } ], "standard_charges": [ { "minimum": 379.33, "maximum": 1265.32, "gross_charge": 1346.09, "discounted_cash": 740.35, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 780.73, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 734.97, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1076.87, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1140.14, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 391.71, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 646.12, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 806.31, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 804.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1265.32, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1184.56, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 379.33, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1144.18, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1009.57, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 474.23, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 915.34, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1265.32, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1053.99, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 734.97, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1070.14, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1009.57, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1184.56, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 780.73, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 734.97, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SENNOSIDES 8.6 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "6362932071", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SENNOSIDES 8.8 MG/5ML PO SYRP", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "48433021940", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.37, "maximum": 4.56, "gross_charge": 4.85, "discounted_cash": 2.67, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.81, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.65, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.88, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.11, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.33, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.91, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.9, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.56, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.27, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.37, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.12, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.64, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.71, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.3, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.56, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.8, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.65, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.86, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.64, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.27, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.81, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.65, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SERTRALINE HCL 100 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687025301", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SERTRALINE HCL 20 MG/ML PO CONC", "drug_information": { "unit": "1.300000", "type": "UN" }, "code_information": [ { "code": "71093014311", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SERTRALINE HCL 25 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687023101", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SERTRALINE HCL 50 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687024201", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SEVELAMER CARBONATE 0.8 G PO PACK", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "65862093090", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.21, "maximum": 4.02, "gross_charge": 4.28, "discounted_cash": 2.35, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.48, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.34, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.42, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.63, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.25, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.05, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.56, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.56, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.02, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.77, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.21, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.64, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.21, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.51, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.91, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.02, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.35, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.34, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.21, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.77, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.48, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.34, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SEVELAMER CARBONATE 2.4 G PO PACK", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "65862093190", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.21, "maximum": 4.02, "gross_charge": 4.28, "discounted_cash": 2.35, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.48, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.34, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.42, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.63, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.25, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.05, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.56, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.56, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.02, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.77, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.21, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.64, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.21, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.51, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.91, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.02, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.35, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.34, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.21, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.77, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.48, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.34, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SEVELAMER CARBONATE 800 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "50268072015", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Sever cranial nerve", "code_information": [ { "code": "64771", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1439.39, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1066.21, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 5989.79, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 10868.56, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1439.39, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 10868.56, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SEVOFLURANE IN SOLN", "drug_information": { "unit": "250.000000", "type": "UN" }, "code_information": [ { "code": "00074445604", "type": "NDC" } ], "standard_charges": [ { "minimum": 42.08, "maximum": 1158.0, "gross_charge": 149.33, "discounted_cash": 82.13, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.61, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 81.53, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 129.62, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.46, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 71.68, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 89.45, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 89.3, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 140.37, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 131.41, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.08, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 126.93, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 112.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.61, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 101.54, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 140.37, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 116.93, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 81.53, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 118.72, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 112.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 131.41, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.61, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 81.53, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Sex transformation f to m", "code_information": [ { "code": "55980", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2542.24, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1883.14, "standard_charge_percentage": 100.0, 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28161.05, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Sho arthrs srg compl synvct", "code_information": [ { "code": "29821", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2391.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1771.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 17972.77, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 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"payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 16919.93, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 30701.52, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2391.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 30701.52, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Sho arthrs srg lmtd dbrdmt", "code_information": [ { "code": "29822", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2391.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1771.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 11709.9, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 21247.81, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2391.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 21247.81, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Sho arthrs srg lss&rescj ads", "code_information": [ { "code": "29825", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2391.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1771.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 10990.29, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 19977.83, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2391.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 19977.83, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Sho arthrs srg rmvl loose/fb", "code_information": [ { "code": "29819", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2391.6, "gross_charge": 0.01, 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"additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 31780.17, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5265.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 31780.17, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Sho arthrs srg rt8tr cuf rpr", "code_information": [ { "code": "29827", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 5265.64, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", 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"methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Sho arthrs srg xtnsv dbrdmt", "code_information": [ { "code": "29823", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2391.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1771.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 16840.04, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 30556.52, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2391.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 30556.52, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Shorten radius or ulna", "code_information": [ { "code": "25390", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 5265.64, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3900.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 19758.58, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 35852.25, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5265.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 35852.25, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Sig w/tndsc balloon dilation", "code_information": [ { "code": "45340", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 869.1, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 643.78, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 4114.09, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 7465.09, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 869.1, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 7465.09, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Sigmoidoscopy & polypectomy", "code_information": [ { "code": "45333", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 672.02, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 497.79, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 3807.3, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 6908.4, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 672.02, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 6908.4, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Sigmoidoscopy and biopsy", "code_information": [ { "code": "45331", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 672.02, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 497.79, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 2980.96, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 5409.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 672.02, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 5409.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Sigmoidoscopy for bleeding", "code_information": [ { "code": "45334", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 869.1, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 643.78, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 6548.62, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 11882.59, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 869.1, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 11882.59, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Sigmoidoscopy w/ablation", "code_information": [ { "code": "45346", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 869.1, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 643.78, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 3296.29, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 5981.18, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 869.1, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 5981.18, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Sigmoidoscopy w/fb removal", "code_information": [ { "code": "45332", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 869.1, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 643.78, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 3711.71, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 6734.95, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 869.1, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 6734.95, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Sigmoidoscopy w/plcmt stent", "code_information": [ { "code": "45347", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4387.82, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3250.23, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 4146.87, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 7524.58, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4387.82, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 7524.58, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Sigmoidoscopy w/resection", "code_information": [ { "code": "45349", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2021.42, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1497.34, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 5226.6, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 9483.76, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2021.42, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 9483.76, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Sigmoidoscopy w/submuc inj", "code_information": [ { "code": "45335", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 672.02, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 497.79, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 4305.28, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 7812.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 672.02, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 7812.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Sigmoidoscopy w/tumr remove", "code_information": [ { "code": "45338", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 869.1, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 643.78, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 3865.47, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 7013.95, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 869.1, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 7013.95, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Sigmoidoscopy w/ultrasound", "code_information": [ { "code": "45341", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 672.02, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 497.79, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 3240.51, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 5879.95, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 672.02, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 5879.95, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Sigmoidoscopy w/us guide bx", "code_information": [ { "code": "45342", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 869.1, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 643.78, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 4340.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 7875.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 869.1, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 7875.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SILDENAFIL CITRATE 10 MG/12.5ML IV SOLN", "drug_information": { "unit": "12.500000", "type": "UN" }, "code_information": [ { "code": "55150016613", "type": "NDC" } ], "standard_charges": [ { "minimum": 108.32, "maximum": 1158.0, "gross_charge": 384.37, "discounted_cash": 211.4, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 222.93, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 209.87, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 333.63, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 111.85, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 184.5, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 230.24, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 229.85, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 361.31, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 338.25, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 108.32, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 326.71, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 288.28, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 135.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 261.37, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 361.31, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 300.96, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 209.87, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 305.57, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 288.28, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 338.25, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 222.93, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 209.87, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SILDENAFIL CITRATE 10 MG/ML PO SUSR", "drug_information": { "unit": "0.500000", "type": "UN" }, "code_information": [ { "code": "2724117529", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SILDENAFIL CITRATE 100 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "R0069422030", "type": "NDC" } ], "standard_charges": [ { "minimum": 28.09, "maximum": 93.7, "gross_charge": 99.68, "discounted_cash": 54.82, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 57.81, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.43, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 79.74, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 84.43, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.85, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.71, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.61, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.7, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.72, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.09, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 84.73, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.76, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.12, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 67.78, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.7, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 78.05, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.43, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 79.25, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.76, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.72, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 57.81, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.43, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SILDENAFIL CITRATE 20 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "50268071715", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SILDENAFIL CITRATE 25 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00069420030", "type": "NDC" } ], "standard_charges": [ { "minimum": 66.94, "maximum": 223.3, "gross_charge": 237.55, "discounted_cash": 130.65, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 137.78, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 129.7, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 190.04, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 201.2, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 69.13, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 114.02, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 142.29, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 142.05, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 223.3, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 209.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 66.94, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 201.92, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 178.16, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 83.69, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 161.53, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 223.3, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 186.0, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 129.7, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 188.85, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 178.16, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 209.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 137.78, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 129.7, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SILDENAFIL CITRATE 50 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "R0069421030", "type": "NDC" } ], "standard_charges": [ { "minimum": 28.09, "maximum": 93.7, "gross_charge": 99.68, "discounted_cash": 54.82, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 57.81, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.43, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 79.74, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 84.43, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.85, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.71, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.61, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.7, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.72, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.09, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 84.73, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.76, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.12, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 67.78, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.7, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 78.05, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.43, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 79.25, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.76, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.72, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 57.81, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.43, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SILODOSIN 4 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "33342038407", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SILODOSIN 8 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "69238142003", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SILTUXIMAB 400 MG IV SOLR", "drug_information": { "unit": "20.000000", "type": "UN" }, "code_information": [ { "code": "73090042101", "type": "NDC" } ], "standard_charges": [ { "minimum": 85.76, "maximum": 17393.31, "gross_charge": 18503.52, "discounted_cash": 10176.94, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 10732.04, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 85.76, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14802.82, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15672.48, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5384.52, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8881.69, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 11083.61, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 11065.1, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17393.31, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16283.1, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 5214.29, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15727.99, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13877.64, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 6518.79, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 12582.39, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 17393.31, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 14488.26, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 115.78, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 14710.3, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13877.64, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16283.1, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 10732.04, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 85.76, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "SILVER NITRATE-POT NITRATE 75-25 % EX MISC", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "12870000102", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": 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"percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", 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"additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SILVER SULFADIAZINE 1 % CREA 50GM (BULK CHARGE)", "drug_information": { "unit": "50.000000", "type": "GR" }, "code_information": [ { "code": "67877012450", "type": "NDC" } ], "standard_charges": [ { "minimum": 7.82, "maximum": 26.09, "gross_charge": 27.75, "discounted_cash": 15.26, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.1, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.15, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.08, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.32, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.62, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.59, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.09, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.42, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.82, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.59, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.81, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.78, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": 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"percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.81, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.42, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.1, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.15, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SILVER SULFADIAZINE 1 % EX CREA", "drug_information": { "unit": "50.000000", "type": "GR" }, "code_information": [ { "code": "67877012450_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 7.82, "maximum": 26.09, "gross_charge": 27.75, "discounted_cash": 15.26, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.1, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.15, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.08, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.32, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.62, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.59, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.09, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.42, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.82, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.59, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.81, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.78, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.87, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.09, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.73, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.15, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.06, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.81, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.42, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.1, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.15, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SIMETHICONE 40 MG/0.6ML PO SUSP", "drug_information": { "unit": "15.000000", "type": "UN" }, "code_information": [ { "code": "46122054703", "type": "NDC" }, { "code": "4628750630", "type": "NDC" }, { "code": "4628750630_2", "type": "NDC" }, { "code": "62372063015_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.61, "maximum": 5.39, "gross_charge": 5.73, "discounted_cash": 3.15, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.58, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.85, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.67, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.75, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.43, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.43, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.39, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.61, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.87, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.3, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.02, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.9, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.39, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.49, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.56, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.3, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", 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{ "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.67, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.71, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.38, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SIMETHICONE 40 MG/0.6ML PO SUSP (NICU)", "drug_information": { "unit": "0.150000", "type": "UN" }, "code_information": [ { "code": "0536222075", "type": "NDC" }, { "code": "0536222075_2", "type": "NDC" }, { "code": "56184012041", "type": "NDC" }, { "code": "62372063015", "type": "NDC" } ], "standard_charges": [ { 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"additional_generic_notes": "" }, { "minimum": 3.32, "maximum": 11.07, "gross_charge": 11.78, "discounted_cash": 6.48, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.83, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.43, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.42, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.98, "standard_charge_percentage": 85.0, "methodology": 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total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SIMETHICONE 80 MG PO CHEW", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "77333081210", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, 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"standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Simple cystometrogram", "code_information": [ { "code": "51725", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 179.27, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 132.79, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 7921.12, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 14731.78, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 179.27, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 14731.78, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SIMPLE SYRUP PO SYRP", "drug_information": { "unit": "473.000000", "type": "UN" }, "code_information": [ { "code": "31722093747", "type": "NDC" } ], "standard_charges": [ { "minimum": 7.61, "maximum": 25.38, "gross_charge": 27.0, "discounted_cash": 14.85, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.66, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.74, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.6, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.87, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.86, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.96, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.17, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.15, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.38, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.76, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.61, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.95, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.25, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.51, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.36, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.38, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.14, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.74, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.47, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.25, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.76, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.66, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.74, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SIMVASTATIN 10 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68084051101", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SIMVASTATIN 20 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "63739057210", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SIMVASTATIN 40 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687021001", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SIMVASTATIN 5 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "63739057010", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SIMVASTATIN 80 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68180046506", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SINCALIDE 5 MCG IJ SOLR", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "63323057905", "type": "NDC" } ], "standard_charges": [ { "minimum": 52.95, "maximum": 176.62, "gross_charge": 187.89, "discounted_cash": 103.34, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 108.98, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 102.59, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 150.31, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 159.14, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.68, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 90.19, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 112.55, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 112.36, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 176.62, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 165.34, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.95, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 159.71, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 140.92, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 66.19, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 127.77, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 176.62, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 147.12, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 102.59, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 149.37, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 140.92, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 165.34, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 108.98, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 102.59, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SINUS RINSE KIT NA PACK", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "05928000100", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SIROLIMUS 0.5 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "1671418701", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.8, "maximum": 9.33, "gross_charge": 9.93, "discounted_cash": 5.46, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.76, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.42, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.94, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.41, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.89, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.77, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.95, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.94, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.33, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.74, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.8, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.44, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.45, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.5, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.75, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.33, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.78, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.42, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.89, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.45, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.74, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.76, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.42, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SIROLIMUS 1 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68084091525", "type": "NDC" } ], "standard_charges": [ { "minimum": 3.8, "maximum": 12.68, "gross_charge": 13.49, "discounted_cash": 7.42, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.82, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.79, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.43, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.93, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.48, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.08, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.07, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.68, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.87, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.8, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.47, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.12, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.17, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.68, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.56, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.72, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.12, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.87, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.82, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SIROLIMUS 1 MG/ML PO SOLN", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "66689034702", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.73, "maximum": 9.1, "gross_charge": 9.68, "discounted_cash": 5.32, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.61, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.29, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.74, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.2, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.82, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.65, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.8, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.79, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.1, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.73, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.23, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.26, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.58, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.1, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.58, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.29, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.7, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.26, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.61, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.29, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SITAGLIPTIN PHOSPHATE 100 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00006027728", "type": "NDC" } ], "standard_charges": [ { "minimum": 10.36, "maximum": 34.55, "gross_charge": 36.76, "discounted_cash": 20.22, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.07, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.41, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.14, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.7, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.64, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.02, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.98, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.55, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.35, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.36, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.25, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.57, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.95, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.0, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.55, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.78, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.07, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.22, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.57, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.35, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.07, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SITAGLIPTIN PHOSPHATE 25 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00006022128", "type": "NDC" } ], "standard_charges": [ { "minimum": 10.36, "maximum": 34.55, "gross_charge": 36.76, "discounted_cash": 20.22, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.07, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.41, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.14, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.7, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.64, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.02, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.98, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.55, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.35, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.36, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.25, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.57, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.95, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.0, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.55, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.78, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.07, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.22, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.57, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.35, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.07, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SITAGLIPTIN PHOSPHATE 50 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00006011228", "type": "NDC" } ], "standard_charges": [ { "minimum": 10.36, "maximum": 34.55, "gross_charge": 36.76, "discounted_cash": 20.22, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.07, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.41, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.14, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.7, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.64, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.02, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.98, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.55, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.35, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.36, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.25, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.57, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.95, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.0, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.55, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.78, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.07, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.22, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.57, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.35, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.07, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SITAGLIPTIN-METFORMIN HCL 50-1000 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00006057761", "type": "NDC" } ], "standard_charges": [ { "minimum": 5.18, "maximum": 17.28, "gross_charge": 18.38, "discounted_cash": 10.11, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.66, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.04, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.7, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.57, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.35, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.82, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.01, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.99, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.28, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.17, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.18, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.62, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.79, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.48, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.5, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.28, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.39, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.04, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.61, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.79, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.17, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.66, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.04, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Skin splt grft trnk/arm/leg", "code_information": [ { "code": "15100", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1348.33, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 998.76, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 7295.57, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 13237.92, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1348.33, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 13237.92, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Skin sub graft face/nk/hf/g", "code_information": [ { "code": "15275", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1348.33, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 998.76, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 11765.35, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 21348.4, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1348.33, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 21348.4, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Skin sub graft trnk/arm/leg", "code_information": [ { "code": "15271", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1348.33, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 998.76, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 10623.5, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 19276.5, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1348.33, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 19276.5, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Skin sub grft t/arm/lg child", "code_information": [ { "code": "15273", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2698.5, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1998.89, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 37246.83, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 67584.97, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2698.5, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 67584.97, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Skn splt a-grft fac/nck/hf/g", "code_information": [ { "code": "15120", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2698.5, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1998.89, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 11260.52, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 20432.39, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2698.5, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 20432.39, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Skn sub grft f/n/hf/g child", "code_information": [ { "code": "15277", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1348.33, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 998.76, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 21249.59, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 38557.73, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1348.33, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 38557.73, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Slitting of prepuce", "code_information": [ { "code": "54001", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1509.96, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1118.49, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 9085.7, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 16486.15, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1509.96, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 16486.15, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Small bowel endoscopy", "code_information": [ { "code": "44360", "type": "HCPCS" }, { "code": "44363", "type": "HCPCS" }, { "code": "44364", "type": "HCPCS" }, { "code": "44365", "type": "HCPCS" }, { "code": "44366", "type": "HCPCS" }, { "code": "44369", "type": "HCPCS" }, { "code": "44372", "type": "HCPCS" }, { "code": "44373", "type": "HCPCS" }, { "code": "44376", "type": "HCPCS" }, { "code": "44378", "type": "HCPCS" }, { "code": "44382", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1398.27, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1035.76, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 511.91, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 4721.91, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 8568.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1398.27, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 691.08, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 8568.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Small bowel endoscopy br/wa", "code_information": [ { "code": "44380", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 691.08, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 511.91, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 2678.4, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 4860.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 691.08, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 4860.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Small bowel endoscopy/biopsy", "code_information": [ { "code": "44361", "type": "HCPCS" }, { "code": "44377", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1398.27, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1035.76, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 3045.44, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 7587.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1398.27, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 7587.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SMX 4 MG/TMP 0.8 MG/1 ML FOR DESENSITIZATION", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "R6586249605", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SMX 40 MCG/TMP 8 MCG/1 ML FOR DESENSITIZATION", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "R6586249605_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SMX 400 MCG/TMP 80 MCG/1 ML FOR DESENSITIZATION", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "R6586249605_3", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SOD BENZ-SOD PHENYLACET 10-10 % IV SOLN", "drug_information": { "unit": "20.000000", "type": "UN" }, "code_information": [ { "code": "70710192601", "type": "NDC" } ], "standard_charges": [ { "minimum": 1148.52, "maximum": 3831.11, "gross_charge": 4075.65, "discounted_cash": 2241.61, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2363.88, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2225.3, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3537.66, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1186.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1956.31, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2441.31, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2437.24, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3831.11, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3586.57, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1148.52, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3464.3, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3056.74, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1435.85, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2771.44, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3831.11, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3191.23, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2225.3, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3240.14, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3056.74, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3586.57, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2363.88, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2225.3, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SOD BICARB-CITRIC AC-SIMETH 2.21-1.53-0.04 G PO PACK", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "10361079301", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SOD CITRATE-CITRIC ACID 500-334 MG/5ML PO SOLN", "drug_information": { "unit": "30.000000", "type": "UN" }, "code_information": [ { "code": "57237031931", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.41, "maximum": 8.03, "gross_charge": 8.54, "discounted_cash": 4.7, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.95, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.66, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.83, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.23, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.49, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.1, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.12, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.11, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.03, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.41, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.26, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.41, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.01, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.81, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.03, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.69, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.66, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.79, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.41, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.95, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.66, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SODIUM ACETATE 2 MEQ/ML IV SOLN", "drug_information": { "unit": "20.000000", "type": "UN" }, "code_information": [ { "code": "00409729973", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 1158.0, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.72, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SODIUM BENZOATE 5 G/30 ML ORAL SOLUTION", "drug_information": { "unit": "500.000000", "type": "UN" }, "code_information": [ { "code": "00000001988", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 1158.0, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.47, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SODIUM BICARBONATE 1 MEQ/ML INFUSION", "drug_information": { "unit": "50.000000", "type": "UN" }, "code_information": [ { "code": "51754500104", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 1158.0, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 95.48, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SODIUM BICARBONATE 1 MEQ/ML PREDILUTION SOLUTION", "drug_information": { "unit": "50.000000", "type": "UN" }, "code_information": [ { "code": "51754500104_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 1158.0, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 95.48, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SODIUM BICARBONATE 2% SOLUTION", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "P0517155026", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SODIUM BICARBONATE 325 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00223172001", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": 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total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SODIUM BICARBONATE 4.2 % IV SOLN", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "00409553414", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.49, "maximum": 1158.0, "gross_charge": 40.76, "discounted_cash": 22.42, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.25, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.38, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.86, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.56, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.42, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.37, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.31, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.87, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.49, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.65, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.57, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.36, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.31, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.92, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.25, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.4, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.57, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.87, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.25, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SODIUM BICARBONATE 650 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "77333082710", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SODIUM BICARBONATE 8.4 % IV SOLN", "drug_information": { "unit": "50.000000", "type": "UN" }, "code_information": [ { "code": "76329335201", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 1158.0, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.72, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SODIUM BICARBONATE 8.4 % IV SOLN -CODE USE PEDS", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "00409490014", "type": "NDC" } ], "standard_charges": [ { "minimum": 14.04, "maximum": 1158.0, "gross_charge": 49.84, "discounted_cash": 27.41, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.91, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.21, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.26, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.5, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.85, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.8, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.85, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.86, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.04, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.36, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.38, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.56, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.89, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.85, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.02, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.21, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.62, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.38, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.86, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.91, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.21, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SODIUM BICARBONATE 8.4 % IV SOLN 50 ML SYRINGE (BULK CHARGE)", "drug_information": { "unit": "50.000000", "type": "UN" }, "code_information": [ { "code": "76329335201_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 1158.0, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.72, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, 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"additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SODIUM BICARBONATE 8.4 % IV SYRINGE", "drug_information": { "unit": "50.000000", "type": "UN" }, "code_information": [ { "code": "00409663714", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 1158.0, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.72, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SODIUM CHLORIDE (HYPERTONIC) 2 % OP SOLN", "drug_information": { "unit": "15.000000", "type": "UN" }, "code_information": [ { "code": "24208027615", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SODIUM CHLORIDE (HYPERTONIC) 5 % OP OINT", "drug_information": { "unit": "4.000000", "type": "GR" }, "code_information": [ { "code": "24208038555", "type": "NDC" } ], "standard_charges": [ { "minimum": 21.42, "maximum": 71.44, "gross_charge": 76.0, "discounted_cash": 41.8, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", 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"NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": 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94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SODIUM CHLORIDE (PF) 0.9 % IJ SOLN", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "00409488810", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SODIUM CHLORIDE (PF) 0.9 % IJ SOLN INTRATHECAL SYRINGE", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "63323018610_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": 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"payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SODIUM CHLORIDE (PF) 0.9 % INJ SOLN 50 ML VIAL (BULK CHARGE)", "drug_information": { "unit": "50.000000", "type": "UN" }, "code_information": [ { "code": "00409488850", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SODIUM CHLORIDE 0.45 % IV BOLUS", "drug_information": { "unit": "1000.000000", "type": "UN" }, "code_information": [ { "code": "00338004304", "type": "NDC" } ], "standard_charges": [ { "minimum": 19.73, "maximum": 1158.0, "gross_charge": 70.0, "discounted_cash": 38.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.76, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.37, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.93, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.86, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.73, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.66, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.6, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.81, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.65, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SODIUM CHLORIDE 0.45 % IV SOLN", "drug_information": { "unit": "1000.000000", "type": "UN" }, "code_information": [ { "code": "00338004304_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 19.73, "maximum": 1158.0, "gross_charge": 70.0, "discounted_cash": 38.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.76, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.37, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.93, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.86, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.73, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.66, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.6, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.81, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.65, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SODIUM CHLORIDE 0.45 % IV SOLN 1000ML (BULK CHARGE)", "drug_information": { "unit": "1000.000000", "type": "UN" }, "code_information": [ { "code": "00338004304_3", "type": "NDC" } ], "standard_charges": [ { "minimum": 19.73, "maximum": 1158.0, "gross_charge": 70.0, "discounted_cash": 38.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.76, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.37, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.93, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.86, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.73, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.66, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.6, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.81, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.65, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SODIUM CHLORIDE 0.45 % IV SOLN 500ML (BULK CHARGE)", "drug_information": { "unit": "500.000000", "type": "UN" }, "code_information": [ { "code": "00338004303", "type": "NDC" } ], "standard_charges": [ { "minimum": 19.73, "maximum": 1158.0, "gross_charge": 70.0, "discounted_cash": 38.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.76, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.37, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.93, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.86, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.73, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.66, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.6, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.81, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.65, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SODIUM CHLORIDE 0.45 % POSTDILUTION SOLUTION", "drug_information": { "unit": "1000.000000", "type": "UN" }, "code_information": [ { "code": "00338004304_4", "type": "NDC" } ], "standard_charges": [ { "minimum": 19.73, "maximum": 1158.0, "gross_charge": 70.0, "discounted_cash": 38.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.76, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.37, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.93, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.86, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.73, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.66, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.6, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.81, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.65, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SODIUM CHLORIDE 0.45 % PREDILUTION SOLUTION", "drug_information": { "unit": "1000.000000", "type": "UN" }, "code_information": [ { "code": "00338004304_5", "type": "NDC" } ], "standard_charges": [ { "minimum": 19.73, "maximum": 1158.0, "gross_charge": 70.0, "discounted_cash": 38.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.76, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.37, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.93, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.86, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.73, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.66, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.6, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.81, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.65, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SODIUM CHLORIDE 0.45 %/20 MEQ KCL", "drug_information": { "unit": "1000.000000", "type": "UN" }, "code_information": [ { "code": "00338070434", "type": "NDC" } ], "standard_charges": [ { "minimum": 28.18, "maximum": 94.0, "gross_charge": 100.0, "discounted_cash": 55.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 58.0, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.6, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 80.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 84.7, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.1, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 48.0, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.9, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.8, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 94.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.18, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 85.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.23, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 68.0, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 94.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 78.3, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.6, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 79.5, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 58.0, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.6, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SODIUM CHLORIDE 0.45 %/20 MEQ KCL (MULTI-GPI)", "drug_information": { "unit": "1000.000000", "type": "UN" }, "code_information": [ { "code": "00338070434_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 28.18, "maximum": 94.0, "gross_charge": 100.0, "discounted_cash": 55.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 58.0, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.6, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 80.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 84.7, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.1, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 48.0, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.9, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.8, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 94.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.18, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 85.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.23, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 68.0, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 94.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 78.3, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.6, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 79.5, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 58.0, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.6, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SODIUM CHLORIDE 0.45% IV BOLUS FOR REPLACEMENT", "drug_information": { "unit": "1000.000000", "type": "UN" }, "code_information": [ { "code": "00264780200", "type": "NDC" } ], "standard_charges": [ { "minimum": 19.73, "maximum": 1158.0, "gross_charge": 70.0, "discounted_cash": 38.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.76, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.37, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.93, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.86, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.73, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.66, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.6, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.81, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.65, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SODIUM CHLORIDE 0.45%/20 MEQ KCL (REPLACEMENT)", "drug_information": { "unit": "1000.000000", "type": "UN" }, "code_information": [ { "code": "00338070434_3", "type": "NDC" } ], "standard_charges": [ { "minimum": 28.18, "maximum": 94.0, "gross_charge": 100.0, "discounted_cash": 55.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 58.0, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.6, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 80.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 84.7, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.1, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 48.0, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.9, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.8, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 94.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.18, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 85.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.23, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 68.0, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 94.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 78.3, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.6, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 79.5, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 58.0, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.6, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SODIUM CHLORIDE 0.9 % (PF) SOLN", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "63323018610_4", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SODIUM CHLORIDE 0.9 % BOLUS (APHERESIS)", "drug_information": { "unit": "1000.000000", "type": "UN" }, "code_information": [ { "code": "00338004904", "type": "NDC" } ], "standard_charges": [ { "minimum": 19.73, "maximum": 1158.0, "gross_charge": 70.0, "discounted_cash": 38.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.76, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.37, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.93, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.86, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.73, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.66, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.6, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.81, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.65, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SODIUM CHLORIDE 0.9 % IR SOLN", "drug_information": { "unit": "1000.000000", "type": "UN" }, "code_information": [ { "code": "00338004804", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SODIUM CHLORIDE 0.9 % IRRIGATION SOLN 3000ML BAG (BULK CHARGE)", "drug_information": { "unit": "3000.000000", "type": "UN" }, "code_information": [ { "code": "00338004747", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SODIUM CHLORIDE 0.9 % IV 100 ML (LINE CARE)", "drug_information": { "unit": "100.000000", "type": "UN" }, "code_information": [ { "code": "00338004938", "type": "NDC" } ], "standard_charges": [ { "minimum": 19.73, "maximum": 1158.0, "gross_charge": 70.0, "discounted_cash": 38.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.76, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.37, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.93, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.86, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.73, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.66, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.6, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.81, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.65, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SODIUM CHLORIDE 0.9 % IV 250 ML (LINE CARE)", "drug_information": { "unit": "250.000000", "type": "UN" }, "code_information": [ { "code": "00338004902", "type": "NDC" } ], "standard_charges": [ { "minimum": 19.73, "maximum": 1158.0, "gross_charge": 70.0, "discounted_cash": 38.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.76, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.37, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.93, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.86, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.73, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.66, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.6, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.81, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.65, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SODIUM CHLORIDE 0.9 % IV 50 ML (LINE CARE)", "drug_information": { "unit": "50.000000", "type": "UN" }, "code_information": [ { "code": "00264180031", "type": "NDC" } ], "standard_charges": [ { "minimum": 19.73, "maximum": 65.8, "gross_charge": 70.0, "discounted_cash": 38.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 56.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.29, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.37, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.93, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.86, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.73, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.66, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.6, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.81, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.65, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SODIUM CHLORIDE 0.9 % IV 500 ML (LINE CARE)", "drug_information": { "unit": "500.000000", "type": "UN" }, "code_information": [ { "code": "00338954304", "type": "NDC" } ], "standard_charges": [ { "minimum": 19.73, "maximum": 1158.0, "gross_charge": 70.0, "discounted_cash": 38.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.76, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.37, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.93, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.86, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.73, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.66, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.6, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.81, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.65, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SODIUM CHLORIDE 0.9 % IV BOLUS", "drug_information": { "unit": "1000.000000", "type": "UN" }, "code_information": [ { "code": "00338004904_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 19.73, "maximum": 1158.0, "gross_charge": 70.0, "discounted_cash": 38.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.76, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.37, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.93, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.86, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.73, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.66, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.6, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.81, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.65, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SODIUM CHLORIDE 0.9 % IV BOLUS (PEDS DKA)", "drug_information": { "unit": "1000.000000", "type": "UN" }, "code_information": [ { "code": "00338004904_3", "type": "NDC" } ], "standard_charges": [ { "minimum": 19.73, "maximum": 1158.0, "gross_charge": 70.0, "discounted_cash": 38.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.76, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.37, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.93, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.86, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.73, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.66, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.6, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.81, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.65, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SODIUM CHLORIDE 0.9 % IV BOLUS (SEPSIS)", "drug_information": { "unit": "1000.000000", "type": "UN" }, "code_information": [ { "code": "00338004904_4", "type": "NDC" } ], "standard_charges": [ { "minimum": 19.73, "maximum": 1158.0, "gross_charge": 70.0, "discounted_cash": 38.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.76, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.37, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.93, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.86, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.73, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.66, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.6, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.81, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.65, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SODIUM CHLORIDE 0.9 % IV SOLN", "drug_information": { "unit": "1000.000000", "type": "UN" }, "code_information": [ { "code": "00338004904_5", "type": "NDC" } ], "standard_charges": [ { "minimum": 19.73, "maximum": 1158.0, "gross_charge": 70.0, "discounted_cash": 38.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.76, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.37, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.93, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.86, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.73, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.66, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.6, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.81, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.65, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SODIUM CHLORIDE 0.9 % IV SOLN (EKOS)", "drug_information": { "unit": "1000.000000", "type": "UN" }, "code_information": [ { "code": "00338004904_6", "type": "NDC" } ], "standard_charges": [ { "minimum": 19.73, "maximum": 1158.0, "gross_charge": 70.0, "discounted_cash": 38.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.76, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.37, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.93, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.86, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.73, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.66, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.6, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.81, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.65, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SODIUM CHLORIDE 0.9 % IV SOLN (MORGAN LENS)", "drug_information": { "unit": "1000.000000", "type": "UN" }, "code_information": [ { "code": "00338004904_7", "type": "NDC" } ], "standard_charges": [ { "minimum": 19.73, "maximum": 1158.0, "gross_charge": 70.0, "discounted_cash": 38.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.76, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.37, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", 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"plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.66, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.6, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.8, "standard_charge_percentage": 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"standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SODIUM CHLORIDE 0.9 % IV SOLN (PEDS DKA)", "drug_information": { "unit": "1000.000000", "type": "UN" }, "code_information": [ { "code": "00338004904_8", "type": "NDC" } ], "standard_charges": [ { "minimum": 19.73, "maximum": 1158.0, "gross_charge": 70.0, "discounted_cash": 38.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", 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"additional_payer_notes": "N/A", "standard_charge_dollar": 33.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.93, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.86, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.73, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.66, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.6, 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"additional_payer_notes": "N/A", "standard_charge_dollar": 52.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SODIUM CHLORIDE 0.9 % IV SOLN 100 ML (BULK CHARGE)", "drug_information": { "unit": "100.000000", "type": "UN" }, "code_information": [ { "code": "00338004938_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 19.73, "maximum": 1158.0, "gross_charge": 70.0, "discounted_cash": 38.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.76, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.37, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.93, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.86, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.73, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.66, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.6, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.81, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.65, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SODIUM CHLORIDE 0.9 % IV SOLN 1000 ML (BULK CHARGE)", "drug_information": { "unit": "1000.000000", "type": "UN" }, "code_information": [ { "code": "00338004904_9", "type": "NDC" } ], "standard_charges": [ { "minimum": 19.73, "maximum": 1158.0, "gross_charge": 70.0, "discounted_cash": 38.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.76, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.37, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.93, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.86, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.73, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.66, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.6, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.81, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.65, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SODIUM CHLORIDE 0.9 % IV SOLN 250 ML (BULK CHARGE)", "drug_information": { "unit": "250.000000", "type": "UN" }, "code_information": [ { "code": "00338004902_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 19.73, "maximum": 1158.0, "gross_charge": 70.0, "discounted_cash": 38.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.76, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.37, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.93, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.86, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.73, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.66, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.6, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", 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"additional_payer_notes": "N/A", "standard_charge_dollar": 61.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SODIUM CHLORIDE 0.9 % IV SOLN 500 ML (BULK CHARGE)", "drug_information": { "unit": "500.000000", "type": "UN" }, "code_information": [ { "code": "00338954304_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 19.73, "maximum": 1158.0, "gross_charge": 70.0, "discounted_cash": 38.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.76, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.37, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.93, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.86, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.73, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.66, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.6, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.81, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.65, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SODIUM CHLORIDE 0.9 % IV SOLN DEHP FREE", "drug_information": { "unit": "500.000000", "type": "UN" }, 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"standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.37, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.93, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.86, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.73, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.66, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.6, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.81, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.65, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SODIUM CHLORIDE 0.9 % POSTDILUTION SOLUTION", "drug_information": { "unit": "1000.000000", "type": "UN" }, "code_information": [ { "code": "00338004904_10", "type": "NDC" } ], "standard_charges": [ { "minimum": 19.73, "maximum": 1158.0, "gross_charge": 70.0, "discounted_cash": 38.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.76, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.37, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.93, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.86, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.73, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.66, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.6, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.81, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.65, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SODIUM CHLORIDE 0.9 % PREDILUTION SOLUTION", "drug_information": { "unit": "1000.000000", "type": "UN" }, "code_information": [ { "code": "00338004904_11", "type": "NDC" } ], "standard_charges": [ { "minimum": 19.73, "maximum": 1158.0, "gross_charge": 70.0, "discounted_cash": 38.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.76, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.37, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.93, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.86, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.73, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.66, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.6, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.81, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.65, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SODIUM CHLORIDE 0.9 % SOLN (APHERESIS)", "drug_information": { "unit": "500.000000", "type": "UN" }, "code_information": [ { "code": "00338954304_4", "type": "NDC" } ], "standard_charges": [ { "minimum": 19.73, "maximum": 1158.0, "gross_charge": 70.0, "discounted_cash": 38.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.76, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.37, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.93, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.86, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.73, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.66, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.6, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.81, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.65, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SODIUM CHLORIDE 0.9 % SOLN 500 ML (PHOTOPHERESIS)", "drug_information": { "unit": "500.000000", "type": "UN" }, 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"standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.37, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.93, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.86, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.73, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.66, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.6, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.81, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.65, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SODIUM CHLORIDE 0.9 %/20 MEQ KCL", "drug_information": { "unit": "1000.000000", "type": "UN" }, "code_information": [ { "code": "00338069104", "type": "NDC" } ], "standard_charges": [ { "minimum": 28.18, "maximum": 94.0, "gross_charge": 100.0, "discounted_cash": 55.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 58.0, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.6, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 80.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 84.7, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.1, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 48.0, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.9, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.8, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 94.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.18, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 85.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.23, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 68.0, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 94.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 78.3, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.6, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 79.5, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 58.0, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.6, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SODIUM CHLORIDE 0.9 %/40 MEQ KCL", "drug_information": { "unit": "1000.000000", "type": "UN" }, "code_information": [ { "code": "00338069504", "type": "NDC" } ], "standard_charges": [ { "minimum": 28.18, "maximum": 94.0, "gross_charge": 100.0, "discounted_cash": 55.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 58.0, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.6, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 80.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 84.7, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.1, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 48.0, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.9, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.8, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 94.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.18, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 85.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.23, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 68.0, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 94.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 78.3, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.6, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 79.5, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 58.0, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.6, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SODIUM CHLORIDE 0.9% IV SOLN (100 ML)", "drug_information": { "unit": "100.000000", "type": "UN" }, "code_information": [ { "code": "00338004918", "type": "NDC" } ], "standard_charges": [ { "minimum": 19.73, "maximum": 1158.0, "gross_charge": 70.0, "discounted_cash": 38.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.76, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.37, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.93, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.86, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.73, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.66, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.6, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.81, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.65, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SODIUM CHLORIDE 0.9% IV SOLN (1000 ML)", "drug_information": { "unit": "1000.000000", "type": "UN" }, "code_information": [ { "code": "00338004904_12", "type": "NDC" } ], "standard_charges": [ { "minimum": 19.73, "maximum": 1158.0, "gross_charge": 70.0, "discounted_cash": 38.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.76, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.37, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.93, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.86, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.73, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.66, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.6, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.81, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.65, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SODIUM CHLORIDE 0.9% IV SOLN (250 ML)", "drug_information": { "unit": "250.000000", "type": "UN" }, "code_information": [ { "code": "00338004902_3", "type": "NDC" } ], "standard_charges": [ { "minimum": 19.73, "maximum": 1158.0, "gross_charge": 70.0, "discounted_cash": 38.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.76, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.37, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.93, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.86, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.73, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.66, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.6, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.81, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.65, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SODIUM CHLORIDE 0.9% IV SOLN (500 ML)", "drug_information": { "unit": "500.000000", "type": "UN" }, "code_information": [ { "code": "00338004903", "type": "NDC" } ], "standard_charges": [ { "minimum": 19.73, "maximum": 1158.0, "gross_charge": 70.0, "discounted_cash": 38.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.76, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.37, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.93, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.86, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.73, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.66, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.6, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.81, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.65, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SODIUM CHLORIDE 1 G PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "77333084410", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SODIUM CHLORIDE 10 % IN NEBU", "drug_information": { "unit": "2.000000", "type": "UN" }, "code_information": [ { "code": "00378699889", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SODIUM CHLORIDE 23.4 % IV SOLN", "drug_information": { "unit": "30.000000", "type": "UN" }, "code_information": [ { "code": "63323009330_3", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SODIUM CHLORIDE 23.4 % IVPB (30 ML)", "drug_information": { "unit": "30.000000", "type": "UN" }, "code_information": [ { "code": "63323009330_4", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SODIUM CHLORIDE 3 % DRIP (ADULT)", "drug_information": { "unit": "500.000000", "type": "UN" }, "code_information": [ { "code": "00338005403_3", "type": "NDC" } ], "standard_charges": [ { "minimum": 19.73, "maximum": 1158.0, "gross_charge": 70.0, "discounted_cash": 38.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.76, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.37, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.93, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.86, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.73, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.66, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.6, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.81, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.65, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SODIUM CHLORIDE 3 % DRIP (PEDS)", "drug_information": { "unit": "500.000000", "type": "UN" }, "code_information": [ { "code": "00338005403_4", "type": "NDC" } ], "standard_charges": [ { "minimum": 19.73, "maximum": 1158.0, "gross_charge": 70.0, "discounted_cash": 38.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.76, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.37, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.93, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.86, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.73, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.66, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.6, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.81, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.65, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SODIUM CHLORIDE 3 % IN NEBU", "drug_information": { "unit": "15.000000", "type": "UN" }, "code_information": [ { "code": "00378699789", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SODIUM CHLORIDE 3 % IV SOLN", "drug_information": { "unit": "500.000000", "type": "UN" }, "code_information": [ { "code": "00338005403_5", "type": "NDC" } ], "standard_charges": [ { "minimum": 19.73, "maximum": 1158.0, "gross_charge": 70.0, "discounted_cash": 38.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.76, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.37, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.93, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.86, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.73, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.66, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.6, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.81, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.65, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SODIUM CHLORIDE 3 % IVPB (ADULT)", "drug_information": { "unit": "500.000000", "type": "UN" }, "code_information": [ { "code": "00338005403", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SODIUM CHLORIDE 3 % IVPB (PEDS)", "drug_information": { "unit": "500.000000", "type": "UN" }, "code_information": [ { "code": "00338005403_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SODIUM CHLORIDE 3 % SYRINGE", "drug_information": { "unit": "500.000000", "type": "UN" }, "code_information": [ { "code": "00338005403_6", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SODIUM CHLORIDE 3 % SYRINGE (NICU)", "drug_information": { "unit": "500.000000", "type": "UN" }, "code_information": [ { "code": "00338005403_7", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SODIUM CHLORIDE 4 MEQ/ML IV SOLN", "drug_information": { "unit": "30.000000", "type": "UN" }, "code_information": [ { "code": "63323009330", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 1158.0, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.72, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SODIUM CHLORIDE 4 MEQ/ML IV SOLN (FOR DEXTROSE BUILDER)", "drug_information": { "unit": "30.000000", "type": "UN" }, "code_information": [ { "code": "63323009330_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 1158.0, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.72, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SODIUM CHLORIDE 4 MEQ/ML ORAL SOLUTION (EP ORAL)", "drug_information": { "unit": "240.000000", "type": "UN" }, "code_information": [ { "code": "P8252000039", "type": "NDC" } ], "standard_charges": [ { "minimum": 15.89, "maximum": 53.02, "gross_charge": 56.4, "discounted_cash": 31.02, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.71, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.79, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.12, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.77, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.41, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.07, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.73, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 53.02, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.63, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.89, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.94, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.3, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.87, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.35, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 53.02, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 44.16, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.79, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 44.84, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.3, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.63, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.71, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.79, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SODIUM CHLORIDE 4 MEQ/ML PO SOLN", "drug_information": { "unit": "473.000000", "type": "UN" }, "code_information": [ { "code": "48433021501", "type": "NDC" } ], "standard_charges": [ { "minimum": 36.25, "maximum": 120.91, "gross_charge": 128.63, "discounted_cash": 70.75, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.61, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 70.23, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 102.9, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 108.95, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.43, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.74, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 77.05, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 76.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 120.91, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 113.19, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.25, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 109.34, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.47, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.32, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.47, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 120.91, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 100.72, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 70.23, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 102.26, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.47, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 113.19, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.61, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 70.23, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SODIUM CHLORIDE 7 % IN NEBU", "drug_information": { "unit": "4.000000", "type": "UN" }, "code_information": [ { "code": "00487900730", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SODIUM CHLORIDE BACTERIOSTATIC 0.9 % IJ SOLN", "drug_information": { "unit": "30.000000", "type": "UN" }, "code_information": [ { "code": "00409196607", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 1158.0, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.72, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SODIUM CITRATE 4 % VI SOSY", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "69374090605", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SODIUM CITRATE 40 MG/ML LOCK SYRINGE", "drug_information": { "unit": "30.000000", "type": "UN" }, "code_information": [ { "code": "23731603003_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 84.54, "maximum": 1158.0, "gross_charge": 300.0, "discounted_cash": 165.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 174.0, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 163.8, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 260.4, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.3, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 144.0, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 179.7, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 179.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 282.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 264.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 84.54, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 255.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 225.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 105.69, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 204.0, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 282.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 234.9, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 163.8, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 238.5, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 225.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 264.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 174.0, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 163.8, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SODIUM FLUORIDE 1.1 % DT CREA", "drug_information": { "unit": "51.000000", "type": "GR" }, "code_information": [ { "code": "00126028766", "type": "NDC" } ], "standard_charges": [ { "minimum": 12.2, "maximum": 40.7, "gross_charge": 43.3, "discounted_cash": 23.82, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.11, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.64, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.64, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.68, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.6, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.78, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.94, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.7, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.1, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.2, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.81, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.48, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.25, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.44, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.7, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.9, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.64, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.42, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.48, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.1, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.11, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.64, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SODIUM FLUORIDE 1.1 % DT GEL", "drug_information": { "unit": "57.000000", "type": "GR" }, "code_information": [ { "code": "00126028802", "type": "NDC" } ], "standard_charges": [ { "minimum": 24.4, "maximum": 81.4, "gross_charge": 86.6, "discounted_cash": 47.63, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.23, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.28, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human 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85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 64.95, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.51, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 58.89, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 81.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", 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Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.23, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.28, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SODIUM FLUORIDE F 18 10-200 MCI/ML IV SOLN", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "40028051230", "type": "NDC" } ], "standard_charges": [ { "minimum": 115.15, "maximum": 384.11, "gross_charge": 408.63, "discounted_cash": 224.75, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 237.01, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 223.11, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 326.9, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 346.11, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 118.91, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 196.14, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 244.77, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 244.36, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 384.11, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 359.59, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 115.15, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 347.34, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 306.47, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 143.96, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 277.87, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 384.11, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 319.96, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 223.11, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 324.86, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 306.47, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 359.59, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 237.01, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 223.11, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SODIUM HYALURONATE (VISCOSUP) 20 MG/2ML IX SOLN", "drug_information": { "unit": "2.000000", "type": "UN" }, "code_information": [ { "code": "89122072412", "type": "NDC" } ], "standard_charges": [ { "minimum": 169.73, "maximum": 566.18, "gross_charge": 602.32, "discounted_cash": 331.28, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 349.35, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 328.87, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 481.86, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 510.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 175.28, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 289.11, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 360.79, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 360.19, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 566.18, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 530.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 169.73, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 511.97, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 451.74, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 212.2, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 409.58, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 566.18, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 471.62, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 328.87, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 478.84, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 451.74, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 530.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 349.35, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 328.87, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SODIUM HYALURONATE (VISCOSUP) 25 MG/2.5ML IX SOSY", "drug_information": { "unit": "2.500000", "type": "UN" }, "code_information": [ { "code": "89130444401", "type": "NDC" } ], "standard_charges": [ { "minimum": 211.91, "maximum": 706.86, "gross_charge": 751.98, "discounted_cash": 413.59, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 436.15, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 410.58, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 601.58, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 636.93, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 218.83, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 360.95, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 450.44, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 449.68, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 706.86, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 661.74, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 211.91, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 639.18, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 563.99, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 264.92, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 511.35, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 706.86, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 588.8, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 410.58, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 597.82, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 563.99, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 661.74, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 436.15, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 410.58, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SODIUM HYALURONATE 20 MG/2ML IX SOSY (HYALGAN)", "drug_information": { "unit": "2.000000", "type": "UN" }, "code_information": [ { "code": "55566410001", "type": "NDC" } ], "standard_charges": [ { "minimum": 66.24, "maximum": 1315.29, "gross_charge": 1399.24, "discounted_cash": 769.58, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 811.56, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 66.24, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1119.39, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1185.16, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 407.18, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 671.64, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 838.14, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 836.75, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1315.29, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1231.33, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 394.31, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1189.35, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1049.43, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 492.95, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 951.48, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1315.29, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1095.6, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 89.42, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1112.4, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1049.43, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1231.33, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 811.56, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 66.24, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "SODIUM HYALURONATE 30 MG/ML IO SOLN", "drug_information": { "unit": "0.850000", "type": "UN" }, "code_information": [ { "code": "50474054706", "type": "NDC" } ], "standard_charges": [ { "minimum": 54.11, "maximum": 1158.0, "gross_charge": 192.0, "discounted_cash": 105.6, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 111.36, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 104.83, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 166.66, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.87, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 92.16, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 115.01, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 114.82, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 180.48, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 168.96, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.11, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 163.2, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 144.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 67.64, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 130.56, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 180.48, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 150.34, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 104.83, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 152.64, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 144.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 168.96, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 111.36, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 104.83, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SODIUM HYALURONATE 60 MG/3ML IX PRSY", "drug_information": { "unit": "3.000000", "type": "UN" }, "code_information": [ { "code": "89130202001", "type": "NDC" } ], "standard_charges": [ { "minimum": 853.74, "maximum": 2847.81, "gross_charge": 3029.58, "discounted_cash": 1666.27, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1757.16, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1654.15, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2423.66, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2566.05, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 881.61, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1454.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1814.72, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 1811.69, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2847.81, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2666.03, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 853.74, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2575.14, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2272.19, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1067.32, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2060.11, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2847.81, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2372.16, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1654.15, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2408.52, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2272.19, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2666.03, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1757.16, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1654.15, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SODIUM HYALURONATE 8.5 MG/0.85ML IO SOSY", "drug_information": { "unit": "0.850000", "type": "UN" }, "code_information": [ { "code": "08065183085", "type": "NDC" } ], "standard_charges": [ { "minimum": 65.64, "maximum": 1158.0, "gross_charge": 232.92, "discounted_cash": 128.11, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 135.09, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 127.17, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 202.17, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 67.78, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 111.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 139.52, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 139.29, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 218.94, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 204.97, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.64, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 197.98, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 174.69, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.06, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 158.39, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 218.94, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 182.38, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 127.17, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 185.17, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 174.69, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 204.97, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 135.09, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 127.17, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SODIUM IODIDE I 131 CAPSULE DIAGNOSTIC", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "04444000054", "type": "NDC" } ], "standard_charges": [ { "minimum": 112.28, "maximum": 374.52, "gross_charge": 398.43, "discounted_cash": 219.14, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 231.09, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 217.54, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 318.74, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 337.47, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 115.94, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 191.25, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 238.66, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 238.26, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 374.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 350.62, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 112.28, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 338.67, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 298.82, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 140.37, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 270.93, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 374.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 311.97, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 217.54, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 316.75, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 298.82, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 350.62, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 231.09, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 217.54, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SODIUM IODIDE I 131 CAPSULE THERAPEUTIC", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "08252000200", "type": "NDC" } ], "standard_charges": [ { "minimum": 105.68, "maximum": 352.5, "gross_charge": 375.0, "discounted_cash": 206.25, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 217.5, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 204.75, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 300.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 317.63, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 109.13, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 180.0, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 224.63, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 224.25, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 352.5, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 330.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 105.68, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 318.75, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 281.25, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 132.11, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 255.0, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 352.5, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 293.63, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 204.75, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 298.13, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 281.25, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 330.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 217.5, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 204.75, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SODIUM IODIDE I-123 5 MCI CAPSULE", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "51808010201", "type": "NDC" } ], "standard_charges": [ { "minimum": 1693.97, "maximum": 5650.58, "gross_charge": 6011.25, "discounted_cash": 3306.19, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3486.53, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3282.14, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4809.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5091.53, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1749.27, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2885.4, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3600.74, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 3594.73, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5650.58, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5289.9, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1693.97, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5109.56, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4508.44, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2117.76, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4087.65, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5650.58, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4706.81, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3282.14, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4778.94, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4508.44, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5289.9, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3486.53, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3282.14, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SODIUM IODIDE I-123 7.4 (200) MBQ (MICROCURIE) PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "48815100201", "type": "NDC" } ], "standard_charges": [ { "minimum": 66.19, "maximum": 220.81, "gross_charge": 234.9, "discounted_cash": 129.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 136.24, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 128.26, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 187.92, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 198.96, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 68.36, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 112.75, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 140.71, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 140.47, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 220.81, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 206.71, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 66.19, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 199.67, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 176.18, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.76, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 159.73, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 220.81, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 183.93, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 128.26, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 186.75, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 176.18, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 206.71, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 136.24, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 128.26, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SODIUM NITRITE 30 MG/ML IV SOLN", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "60267031110", "type": "NDC" } ], "standard_charges": [ { "minimum": 83.69, "maximum": 1158.0, "gross_charge": 297.0, "discounted_cash": 163.35, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 172.26, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 162.16, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 257.8, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.43, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 142.56, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 177.9, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 177.61, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 279.18, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 261.36, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 83.69, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 252.45, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 222.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 104.63, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 201.96, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 279.18, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 232.55, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 162.16, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 236.12, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 222.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 261.36, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 172.26, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 162.16, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SODIUM NITRITE 30 MG/ML IV SYRINGE (PEDS)", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "60267031110_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 83.69, "maximum": 1158.0, "gross_charge": 297.0, "discounted_cash": 163.35, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 172.26, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 162.16, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 257.8, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.43, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 142.56, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 177.9, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 177.61, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 279.18, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 261.36, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 83.69, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 252.45, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 222.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 104.63, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 201.96, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 279.18, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 232.55, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 162.16, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 236.12, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 222.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 261.36, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 172.26, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 162.16, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SODIUM PHENYLBUTYRATE 3 GM/TSP PO POWD", "drug_information": { "unit": "266.000000", "type": "GR" }, "code_information": [ { "code": "75987007009", "type": "NDC" } ], "standard_charges": [ { "minimum": 7694.52, "maximum": 25666.61, "gross_charge": 27304.9, "discounted_cash": 15017.7, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 15836.84, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 14908.48, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21843.92, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23127.25, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7945.73, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13106.35, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 16355.64, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 11394.0, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 25666.61, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 24028.31, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 7694.52, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23209.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20478.68, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 9619.52, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 18567.33, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 25666.61, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21379.74, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 14908.48, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 15189.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20478.68, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 24028.31, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 15836.84, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 14908.48, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SODIUM PHOSPHATE 3 MMOL/ML (IV FOR PO)", "drug_information": { "unit": "15.000000", "type": "UN" }, "code_information": [ { "code": "63323088116", "type": "NDC" } ], "standard_charges": [ { "minimum": 14.91, "maximum": 49.74, "gross_charge": 52.92, "discounted_cash": 29.11, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.69, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.89, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.34, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 44.82, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.4, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.4, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.7, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.65, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.74, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.57, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.91, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 44.98, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.69, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.64, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.99, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.74, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.44, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.89, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.07, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.69, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.57, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.69, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.89, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SODIUM PHOSPHATES 3 MMOLE/ML IV SOLN (MULTI-GPI)", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "63323088406", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 1158.0, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.72, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SODIUM POLYSTYRENE SULFONATE 15 G/60 ML PO SUSP (PWD RECON)", "drug_information": { "unit": "60.000000", "type": "UN" }, "code_information": [ { "code": "10702003615", "type": "NDC" } ], "standard_charges": [ { "minimum": 7.98, "maximum": 26.63, "gross_charge": 28.33, "discounted_cash": 15.58, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.43, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.47, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.66, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.24, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.97, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.94, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.63, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.93, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.98, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.08, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.25, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.98, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.26, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.63, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.18, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.47, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.52, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.25, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.93, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.43, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.47, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SODIUM POLYSTYRENE SULFONATE 15 GM/60ML CO SUSP", "drug_information": { "unit": "60.000000", "type": "UN" }, "code_information": [ { "code": "46287000660", "type": "NDC" } ], "standard_charges": [ { "minimum": 13.15, "maximum": 43.86, "gross_charge": 46.66, "discounted_cash": 25.66, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.06, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.48, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.33, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.52, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.58, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.4, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.95, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.9, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.86, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.06, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.15, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.66, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.44, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.73, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.86, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.53, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.48, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.09, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.06, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.06, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.48, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SODIUM POLYSTYRENE SULFONATE PO POWD", "drug_information": { "unit": "454.000000", "type": "GR" }, "code_information": [ { "code": "10702003645", "type": "NDC" } ], "standard_charges": [ { "minimum": 43.71, "maximum": 145.79, "gross_charge": 155.1, "discounted_cash": 85.31, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 89.96, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 84.68, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 124.08, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 131.37, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.13, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.45, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 92.9, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 92.75, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 145.79, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 136.49, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.71, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 131.84, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 116.33, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.64, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 105.47, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 145.79, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 121.44, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 84.68, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 123.3, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 116.33, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 136.49, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 89.96, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 84.68, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SODIUM POLYSTYRENE SULFONATE PO POWD FOR FEED DECANTING", "drug_information": { "unit": "454.000000", "type": "GR" }, "code_information": [ { "code": "10702003645_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 43.71, "maximum": 145.79, "gross_charge": 155.1, "discounted_cash": 85.31, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 89.96, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 84.68, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 124.08, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 131.37, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.13, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.45, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 92.9, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 92.75, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 145.79, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 136.49, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.71, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 131.84, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 116.33, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.64, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 105.47, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 145.79, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 121.44, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 84.68, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 123.3, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 116.33, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 136.49, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 89.96, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 84.68, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SODIUM TETRADECYL SULFATE 1 % IV SOLN", "drug_information": { "unit": "0.500000", "type": "UN" }, "code_information": [ { "code": "67457016202", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.84, "maximum": 1158.0, "gross_charge": 42.0, "discounted_cash": 23.1, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.36, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.93, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.46, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.22, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.16, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.16, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.12, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.48, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.96, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.84, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.7, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.8, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.56, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.48, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.89, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.93, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.39, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.96, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.36, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.93, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SODIUM TETRADECYL SULFATE 3 % IV SOLN", "drug_information": { "unit": "2.000000", "type": "UN" }, "code_information": [ { "code": "24201020105", "type": "NDC" } ], "standard_charges": [ { "minimum": 53.6, "maximum": 1158.0, "gross_charge": 190.2, "discounted_cash": 104.61, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 110.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.85, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 165.09, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.35, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 91.3, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 113.93, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 113.74, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 178.79, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 167.38, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 53.6, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 161.67, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 142.65, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 67.01, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 129.34, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 178.79, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 148.93, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.85, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 151.21, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 142.65, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 167.38, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 110.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.85, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SODIUM THIOSULFATE 10% CREAM", "drug_information": { "unit": "20.000000", "type": "GR" }, "code_information": [ { "code": "08252000085", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.53, "maximum": 5.09, "gross_charge": 5.42, "discounted_cash": 2.98, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.14, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.96, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.34, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.59, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.58, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.25, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.24, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.09, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.77, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.53, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.61, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.07, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.91, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.69, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.09, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.24, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.96, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.31, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.07, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.77, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.14, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.96, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SODIUM THIOSULFATE 125 MG/ML IV INTRAVIA", "drug_information": { "unit": "100.000000", "type": "UN" }, "code_information": [ { "code": "73077001001", "type": "NDC" } ], "standard_charges": [ { "minimum": 9652.01, "maximum": 32196.19, "gross_charge": 34251.27, "discounted_cash": 18838.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 19865.74, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 18701.19, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 27401.02, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 29010.83, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9967.12, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16440.61, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", 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charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 29113.58, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 25688.45, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 12066.72, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23290.86, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", 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"additional_payer_notes": "N/A", "standard_charge_dollar": 33.79, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.82, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.64, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.8, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.53, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.11, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.1, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.07, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.97, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.53, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.8, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.79, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.27, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.97, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SODIUM ZIRCONIUM CYCLOSILICATE 5 G PO PACK", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00310110530", "type": "NDC" } ], "standard_charges": [ { "minimum": 10.82, "maximum": 36.1, "gross_charge": 38.4, "discounted_cash": 21.12, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.27, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.97, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.72, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.52, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.17, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.43, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.0, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.1, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.79, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.82, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.64, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.8, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.53, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.11, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.1, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.07, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.97, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.53, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.8, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.79, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.27, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.97, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SOFOSBUVIR 400 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "61958150101", "type": "NDC" } ], "standard_charges": [ { "minimum": 1020.91, "maximum": 3405.43, "gross_charge": 3622.8, "discounted_cash": 1992.54, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2101.22, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1978.05, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2898.24, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3068.51, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1054.23, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1738.94, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2170.06, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2166.43, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3405.43, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3188.06, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1020.91, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3079.38, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2717.1, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1276.31, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2463.5, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3405.43, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2836.65, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1978.05, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2880.13, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2717.1, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3188.06, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2101.22, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1978.05, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SOFOSBUVIR-VELPATASVIR 400-100 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "72626270101", "type": "NDC" } ], "standard_charges": [ { "minimum": 312.4, "maximum": 1042.06, "gross_charge": 1108.57, "discounted_cash": 609.71, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 642.97, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 605.28, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 886.86, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 938.96, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 322.59, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 532.11, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 664.03, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 662.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1042.06, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 975.54, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 312.4, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 942.28, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 831.43, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 390.55, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 753.83, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1042.06, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 868.01, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 605.28, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 881.31, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 831.43, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 975.54, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 642.97, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 605.28, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SOLIFENACIN SUCCINATE 10 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "51248015101", "type": "NDC" } ], "standard_charges": [ { "minimum": 8.2, "maximum": 27.35, "gross_charge": 29.1, "discounted_cash": 16.01, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.88, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.89, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.28, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.65, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.47, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.97, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.43, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.35, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.61, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.2, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.74, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.83, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.25, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.79, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.35, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.79, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.89, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.13, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.83, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.61, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.88, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.89, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SOLIFENACIN SUCCINATE 5 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "67877052730", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", 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Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SOMATROPIN 10 MG SC SOLR", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "55566190101", "type": "NDC" } ], "standard_charges": [ { "minimum": 26.71, "maximum": 1975.17, "gross_charge": 2101.24, "discounted_cash": 1155.68, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1218.72, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.71, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1680.99, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1779.75, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 611.46, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1008.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1258.64, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 1256.54, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1975.17, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1849.09, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 592.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1786.05, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1575.93, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 740.27, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1428.84, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1975.17, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1645.27, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.06, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1670.49, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1575.93, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1849.09, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1218.72, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.71, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "SOMATROPIN 5 MG SC SOLR", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "55566180101", "type": "NDC" } ], "standard_charges": [ { "minimum": 26.71, "maximum": 987.6, "gross_charge": 1050.64, "discounted_cash": 577.85, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 609.37, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.71, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 840.51, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 889.89, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 305.74, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 504.31, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 629.33, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 628.28, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 987.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 924.56, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 296.07, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 893.04, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 787.98, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 370.14, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 714.44, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 987.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 822.65, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.06, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 835.26, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 787.98, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 924.56, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 609.37, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.71, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "SOMATROPIN 6 MG IJ CART", "drug_information": { "unit": "2.900000", "type": "UN" }, "code_information": [ { "code": "00002814701", "type": "NDC" } ], "standard_charges": [ { "minimum": 26.71, "maximum": 5091.17, "gross_charge": 5416.14, "discounted_cash": 2978.88, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3141.36, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.71, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4332.91, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4587.47, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1576.1, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2599.75, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3244.27, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 3238.85, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5091.17, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4766.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1526.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4603.72, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4062.11, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1908.11, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3682.98, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5091.17, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4240.84, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.06, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4305.83, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4062.11, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4766.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3141.36, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.71, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "SORAFENIB TOSYLATE 200 MG PO TABS", "drug_information": { "unit": "2.000000", "type": "UN" }, "code_information": [ { "code": "50419048858", "type": "NDC" } ], "standard_charges": [ { "minimum": 419.39, "maximum": 1398.97, "gross_charge": 1488.27, "discounted_cash": 818.55, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 863.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 812.6, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1190.62, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1260.56, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 433.09, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 714.37, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 891.47, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 889.99, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1398.97, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1309.68, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 419.39, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1265.03, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1116.2, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 524.32, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1012.02, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1398.97, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1165.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 812.6, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1183.17, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1116.2, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1309.68, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 863.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 812.6, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SORBITOL 3 % IR SOLN", "drug_information": { "unit": "3000.000000", "type": "UN" }, "code_information": [ { "code": "00338029547", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 1158.0, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.72, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SORBITOL 70 % SOLN", "drug_information": { "unit": "30.000000", "type": "UN" }, "code_information": [ { "code": "46287050030", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.21, "maximum": 4.03, "gross_charge": 4.29, "discounted_cash": 2.36, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.49, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.34, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.43, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.63, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.25, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.06, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.57, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.57, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.03, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.78, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.21, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.65, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.22, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.51, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.92, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.03, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.36, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.34, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.41, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.22, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.78, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.49, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.34, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SOTALOL HCL 120 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "50268072515", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SOTALOL HCL 150 MG/10ML IV SOLN", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "69724011210", "type": "NDC" } ], "standard_charges": [ { "minimum": 2786.44, "maximum": 9294.72, "gross_charge": 9888.0, "discounted_cash": 5438.4, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5735.04, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5398.85, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7910.4, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8375.14, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2877.41, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4746.24, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5922.91, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 5913.02, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9294.72, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8701.44, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2786.44, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8404.8, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7416.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3483.54, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6723.84, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 9294.72, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7742.3, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5398.85, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7860.96, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7416.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8701.44, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5735.04, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5398.85, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SOTALOL HCL 40 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "3535693530", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SOTALOL HCL 5 MG/ML PO SOLN", "drug_information": { "unit": "250.000000", "type": "UN" }, "code_information": [ { "code": "24338053025", "type": "NDC" } ], "standard_charges": [ { "minimum": 337.0, "maximum": 1124.15, "gross_charge": 1195.9, "discounted_cash": 657.75, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 693.62, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 652.96, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 956.72, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1012.93, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 348.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 574.03, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 716.34, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 715.15, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1124.15, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1052.39, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 337.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1016.52, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 896.93, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 421.32, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 813.21, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1124.15, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 936.39, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 652.96, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 950.74, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 896.93, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1052.39, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 693.62, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 652.96, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SOTALOL HCL 80 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68084065401", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SPESOLIMAB-SBZO 450 MG/7.5ML IV SOLN", "drug_information": { "unit": "7.500000", "type": "UN" }, "code_information": [ { "code": "00597003510", "type": "NDC" } ], "standard_charges": [ { "minimum": 33.54, "maximum": 72097.53, "gross_charge": 76699.5, "discounted_cash": 42184.73, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 44485.71, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.54, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61359.6, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 64964.48, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 22319.55, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 36815.76, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 45943.0, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 11394.0, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 72097.53, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 67495.56, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 21613.92, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 65194.58, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 57524.63, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 27021.23, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 52155.66, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 72097.53, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60055.71, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 15189.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 57524.63, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 67495.56, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 44485.71, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.54, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "Sphenoid sinus surgery", "code_information": [ { "code": "31051", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4360.43, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3229.95, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 9271.96, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 16939.9, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4360.43, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 16939.9, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SPIRONOLACTONE 100 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687048701", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": 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billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SPIRONOLACTONE 12.5 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "0228280311", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SPIRONOLACTONE 25 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687046501", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SPIRONOLACTONE 25 MG/5ML PO SUSP", "drug_information": { "unit": "118.000000", "type": "UN" }, "code_information": [ { "code": "00574113304", "type": "NDC" } ], "standard_charges": [ { "minimum": 119.15, "maximum": 397.46, "gross_charge": 422.83, "discounted_cash": 232.56, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 245.24, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 230.87, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 338.26, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 358.14, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 123.04, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 202.96, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 253.28, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 252.85, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 397.46, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 372.09, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 119.15, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 359.41, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 317.12, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 148.96, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 287.52, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 397.46, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 331.08, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 230.87, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 336.15, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 317.12, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 372.09, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 245.24, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 230.87, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SPIRONOLACTONE 50 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "51079097920", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Stab phleb veins xtr 10-20", "code_information": [ { "code": "37765", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2320.02, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1718.54, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 10773.73, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 19819.13, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2320.02, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 19819.13, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "STERILE WATER FOR INJECTION IJ SOLN", "drug_information": { "unit": "20.000000", "type": "UN" }, "code_information": [ { "code": "00409488720", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "STERILE WATER FOR INJECTION IJ SOLN (10 ML VIAL)", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "00409488710", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "STERILE WATER FOR INJECTION IV SOLN (LARGE VOLUME)", "drug_information": { "unit": "1000.000000", "type": "UN" }, "code_information": [ { "code": "00338001304", "type": "NDC" } ], "standard_charges": [ { "minimum": 19.73, "maximum": 65.8, "gross_charge": 70.0, "discounted_cash": 38.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 56.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.29, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.37, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.93, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.86, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.73, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.66, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.6, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.81, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.65, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "STERILE WATER FOR INJECTION SOLN 10 ML VIAL (BULK CHARGE)", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "00409488710_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "STERILE WATER FOR INJECTION SOLN 50 ML VIAL (BULK CHARGE)", "drug_information": { "unit": "50.000000", "type": "UN" }, "code_information": [ { "code": "00409488750", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "STERILE WATER FOR IRRIGATION FOR ORAL USE", "drug_information": { "unit": "1000.000000", "type": "UN" }, "code_information": [ { "code": "00338000404", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "STERILE WATER FOR IRRIGATION IR SOLN", "drug_information": { "unit": "1000.000000", "type": "UN" }, "code_information": [ { "code": "00338000404_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "STERILE WATER FOR IRRIGATION IR SOLN FOR WAM MIXTURE", "drug_information": { "unit": "1500.000000", "type": "UN" }, "code_information": [ { "code": "00990713936", "type": "NDC" } ], "standard_charges": [ { "minimum": 3.03, "maximum": 10.11, "gross_charge": 10.76, "discounted_cash": 5.92, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.24, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.87, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.61, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.11, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.16, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.45, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.43, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.11, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.47, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.03, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.15, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.07, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.79, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.32, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.11, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.43, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.87, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.55, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.07, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.47, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.24, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.87, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "STREPTOMYCIN SULFATE 1 G IM SOLR", "drug_information": { "unit": "2.500000", "type": "UN" }, "code_information": [ { "code": "39822070602", "type": "NDC" } ], "standard_charges": [ { "minimum": 57.43, "maximum": 191.55, "gross_charge": 203.78, "discounted_cash": 112.08, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 118.19, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 111.26, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 163.02, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 172.6, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.3, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 97.81, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 122.06, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 121.86, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 191.55, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 179.33, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 57.43, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 173.21, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 152.84, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 71.79, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 138.57, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 191.55, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 159.56, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 111.26, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 162.01, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 152.84, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 179.33, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 118.19, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 111.26, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "STREPTOZOCIN 1 G IV SOLR", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "00703463601", "type": "NDC" } ], "standard_charges": [ { "minimum": 355.9, "maximum": 1187.18, "gross_charge": 1262.96, "discounted_cash": 694.63, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 732.52, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 689.58, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1010.37, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1069.73, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 367.52, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 606.22, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 756.51, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 755.25, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1187.18, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1111.4, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 355.9, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1073.52, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 947.22, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 444.94, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 858.81, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1187.18, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 988.9, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 689.58, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1004.05, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 947.22, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1111.4, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 732.52, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 689.58, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "STREPTOZOCIN CHEMO SYRINGE", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "00703463601_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 375.63, "maximum": 1252.98, "gross_charge": 1332.96, "discounted_cash": 733.13, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 773.12, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 727.8, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1066.37, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1129.02, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 387.89, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 639.82, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 798.44, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 797.11, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1252.98, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1173.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 375.63, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1133.02, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 999.72, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 469.6, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 906.41, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1252.98, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1043.71, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 727.8, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1059.7, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 999.72, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1173.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 773.12, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 727.8, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "STRONTIUM CHLORIDE SR-89 1 MCI/ML IV SOLN", "drug_information": { "unit": "4.000000", "type": "UN" }, "code_information": [ { "code": "17156052401", "type": "NDC" } ], "standard_charges": [ { "minimum": 950.43, "maximum": 11280.0, "gross_charge": 12000.0, "discounted_cash": 6600.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 6960.0, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 950.43, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9600.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10164.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3492.0, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5760.0, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7188.0, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 7176.0, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11280.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10560.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3381.6, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10200.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9000.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 4227.6, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 8160.0, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 11280.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 9396.0, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1283.08, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 9540.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9000.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10560.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6960.0, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 950.43, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "Subrta njx rx agt w/vtrc", "code_information": [ { "code": "0810T", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 3133.04, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2320.77, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 7089.62, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 12864.21, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3133.04, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 12864.21, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Subtalar arthro w/exc", "code_information": [ { "code": "29905", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 5265.64, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3900.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 9933.05, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 18075.2, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5265.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 18075.2, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SUCCIMER 100 MG PO CAPS", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "55292020111", "type": "NDC" } ], "standard_charges": [ { "minimum": 77.62, "maximum": 258.91, "gross_charge": 275.44, "discounted_cash": 151.49, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 159.76, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 150.39, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 220.35, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 233.3, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 80.15, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 132.21, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 164.99, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 164.71, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 258.91, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 242.39, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 77.62, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 234.12, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 206.58, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 97.04, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 187.3, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 258.91, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 215.67, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 150.39, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 218.97, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 206.58, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 242.39, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 159.76, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 150.39, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SUCCINYLCHOLINE 20 MG/ML 5ML", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "73177011602", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SUCCINYLCHOLINE CHLORIDE 20 MG/ML IJ SOLN", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "00781341195", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SUCRALFATE 1 G PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "51079075320", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SUCRALFATE 1 GM/10ML PO SUSP", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "50268074514", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.56, "maximum": 8.54, "gross_charge": 9.08, "discounted_cash": 4.99, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.27, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.96, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.26, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.69, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.36, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.44, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.43, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.54, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.99, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.56, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.72, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.81, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.17, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.54, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.11, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.96, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.22, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.81, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.99, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.27, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.96, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Suction lipectomy head&neck", "code_information": [ { "code": "15876", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2698.5, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1998.89, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 14253.54, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 25985.21, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2698.5, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 25985.21, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Suction lipectomy lwr extrem", "code_information": [ { "code": "15879", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2698.5, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1998.89, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 16222.67, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 29436.3, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2698.5, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 29436.3, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Suction lipectomy trunk", "code_information": [ { "code": "15877", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2698.5, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1998.89, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 15094.43, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 27389.09, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2698.5, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 27389.09, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Suction lipectomy upr extrem", "code_information": [ { "code": "15878", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1348.33, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 998.76, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 14702.93, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 26678.7, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1348.33, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 26678.7, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SUFENTANIL CITRATE 100 MCG/2ML IV SOLN", "drug_information": { "unit": "2.000000", "type": "UN" }, "code_information": [ { "code": "00641611110", "type": "NDC" } ], "standard_charges": [ { "minimum": 12.68, "maximum": 1158.0, "gross_charge": 45.0, "discounted_cash": 24.75, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.1, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.06, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.1, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.91, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", 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"percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.85, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.6, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.3, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.24, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.78, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.1, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SUGAMMADEX SODIUM 200 MG/2ML IV SOLN", "drug_information": { "unit": "2.000000", "type": "UN" }, "code_information": [ { "code": "00006542312", "type": "NDC" } ], "standard_charges": [ { "minimum": 115.82, "maximum": 1158.0, "gross_charge": 411.0, "discounted_cash": 226.05, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 238.38, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 224.41, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { 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total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 245.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 386.34, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 361.68, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 115.82, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 349.35, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 308.25, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 144.8, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 279.48, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 386.34, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": 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billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 238.38, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 224.41, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SULFACETAMIDE SODIUM 10 % OP SOLN", "drug_information": { "unit": "15.000000", "type": "UN" }, "code_information": [ { "code": "24208067004", "type": "NDC" } ], "standard_charges": [ { "minimum": 21.25, "maximum": 70.88, "gross_charge": 75.4, "discounted_cash": 41.47, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.73, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.17, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.32, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.86, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.94, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.19, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.16, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.09, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 70.88, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 66.35, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.25, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 64.09, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 56.55, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.56, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 51.27, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 70.88, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.04, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.17, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.94, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 56.55, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 66.35, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.73, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.17, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SULFACETAMIDE-PREDNISOLONE 10-0.23 % OP SOLN", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "24208031705", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SULFADIAZINE 500 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "42806075760", "type": "NDC" } ], "standard_charges": [ { "minimum": 10.23, "maximum": 34.12, "gross_charge": 36.3, "discounted_cash": 19.97, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.05, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.82, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.04, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.75, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.56, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.42, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.74, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.71, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.12, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.94, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.23, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.86, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.23, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.79, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.68, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.12, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.42, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.82, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.86, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.23, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.94, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.05, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.82, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SULFAMETHOXAZOLE-TRIMETHOPRIM 200-40 MG/5ML PO SUSP", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "1785649601", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SULFAMETHOXAZOLE-TRIMETHOPRIM 400-80 MG/5ML IV SOLN", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "70069036210", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 1158.0, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.72, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SULFAMETHOXAZOLE-TRIMETHOPRIM DOUBLE STRENGTH 800-160 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687061401", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SULFAMETHOXAZOLE-TRIMETHOPRIM INTRAVITREAL INJ (1.6 MG/0.1ML)", "drug_information": { "unit": "0.100000", "type": "UN" }, "code_information": [ { "code": "70069036210_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 1158.0, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 95.48, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SULFAMETHOXAZOLE-TRIMETHOPRIM SINGLE STRENGTH 400-80 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687060365", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": 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"percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", 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"additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SULFASALAZINE 100 MG/ML ORAL SUSPENSION", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "P0591079610", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SULFASALAZINE 500 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "59762500005", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SULFASALAZINE 500 MG PO TBEC", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "59762010405", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SULFUR HEXAFLUORIDE MICROSPH 60.7-25 MG IJ SUSR", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "00270709916", "type": "NDC" } ], "standard_charges": [ { "minimum": 74.05, "maximum": 246.99, "gross_charge": 262.76, "discounted_cash": 144.52, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 152.4, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 143.47, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 210.21, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 222.56, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 76.46, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 126.12, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 157.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 157.13, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 246.99, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 231.23, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.05, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 223.35, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 197.07, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 92.57, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 178.68, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 246.99, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 205.74, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 143.47, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 208.89, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 197.07, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 231.23, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 152.4, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 143.47, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SULINDAC 150 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "53489047801", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SUMATRIPTAN 20 MG/ACT NA SOLN", "drug_information": { "unit": "6.000000", "type": "UN" }, "code_information": [ { "code": "45802059806", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.4, "maximum": 104.73, "gross_charge": 111.41, "discounted_cash": 61.28, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 64.62, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.83, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 89.13, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 94.36, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.42, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 53.48, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 66.73, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 66.62, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 104.73, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 98.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.4, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 94.7, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 83.56, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.25, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.76, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 104.73, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.23, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.83, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.57, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 83.56, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 98.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 64.62, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.83, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SUMATRIPTAN 5 MG/ACT NA SOLN", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "45802061906", "type": "NDC" } ], "standard_charges": [ { "minimum": 5.23, "maximum": 17.46, "gross_charge": 18.57, "discounted_cash": 10.21, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.77, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.14, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.86, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.73, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.4, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.91, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.12, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.1, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.46, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.34, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.23, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.78, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.93, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.54, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.63, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.46, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.54, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.14, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.76, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.93, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.34, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.77, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.14, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SUMATRIPTAN SUCCINATE 100 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "55111029398", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SUMATRIPTAN SUCCINATE 25 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "65862014636", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SUMATRIPTAN SUCCINATE 50 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "65862014736", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SUMATRIPTAN SUCCINATE 6 MG/0.5ML SC SOLN", "drug_information": { "unit": "0.500000", "type": "UN" }, "code_information": [ { "code": "55150017301", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SUPER OMEGA-3 1000 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "11845014638", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Surg dx exam anorectal", "code_information": [ { "code": "45990", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2021.42, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1497.34, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 4362.32, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 7915.5, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2021.42, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 7915.5, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Surgery for vulva lesion", "code_information": [ { "code": "56440", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2343.63, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 5167.95, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 9377.35, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2343.63, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 9377.35, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Surgery to stop leg growth", "code_information": [ { "code": "27475", "type": "HCPCS" }, { "code": "27477", "type": "HCPCS" }, { "code": "27479", "type": "HCPCS" }, { "code": "27485", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 5265.64, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3900.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 12515.1, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 22708.85, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5265.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 22708.85, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Surgery/speech prosthesis", "code_information": [ { "code": "31611", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2390.47, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1770.72, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 6514.14, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 11820.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2390.47, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 11820.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SURGICAL SEALANT", "drug_information": { "unit": "4.000000", "type": "UN" }, "code_information": [ { "code": "00000934071", "type": "NDC" } ], "standard_charges": [ { "minimum": 502.54, "maximum": 1676.32, "gross_charge": 1783.32, "discounted_cash": 980.83, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1034.33, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 973.69, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1547.92, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 518.95, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 855.99, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1068.21, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 1066.43, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1676.32, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1569.32, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 502.54, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1515.82, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1337.49, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 628.26, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1212.66, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1676.32, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1396.34, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 973.69, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1417.74, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1337.49, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1569.32, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1034.33, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 973.69, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SURGILUBE EX GEL", "drug_information": { "unit": "57.000000", "type": "GR" }, "code_information": [ { "code": "00281020502", "type": "NDC" } ], "standard_charges": [ { "minimum": 3.25, "maximum": 10.86, "gross_charge": 11.55, "discounted_cash": 6.35, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.7, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.31, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.24, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.78, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.36, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.54, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.91, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.86, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.16, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.25, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.82, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.66, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.07, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.85, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.86, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.04, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.31, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.66, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.16, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.7, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.31, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Suspension of breast", "code_information": [ { "code": "19316", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4806.97, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3560.72, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 19019.6, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 35347.74, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4806.97, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 35347.74, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Suspension of uterus", "code_information": [ { "code": "58400", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 16368.24, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 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total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8370.32, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13806.72, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 17229.64, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 11394.0, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 27038.16, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 25312.32, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 8105.7, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 24449.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21573.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem 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"methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 15189.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21573.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 25312.32, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 16683.12, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 15705.14, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "SUTIMLIMAB-JOME 1100 MG/22ML IV SOLN", "drug_information": { "unit": "22.000000", "type": "UN" }, "code_information": [ { "code": "80203034701", "type": "NDC" } ], "standard_charges": [ { "minimum": 1621.14, "maximum": 5407.63, "gross_charge": 5752.8, "discounted_cash": 3164.04, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3336.62, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3141.03, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs 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billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 3440.17, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5407.63, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5062.46, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1621.14, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4889.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4314.6, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2026.71, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3911.9, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5407.63, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4504.44, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3141.03, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4573.48, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4314.6, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5062.46, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3336.62, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3141.03, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Suture large intestine", "code_information": [ { "code": "44604", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 32373.01, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 58766.47, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 58766.47, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "T-cell depletion of harvest", "code_information": [ { "code": "38210", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 322.25, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 29388.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 53325.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 322.25, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 53325.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TAB-A-VITE/BETA CAROTENE PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00904053061_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TACROLIMUS 0.03 % EX OINT", "drug_information": { "unit": "30.000000", "type": "GR" }, "code_information": [ { "code": "45802039000", "type": "NDC" } ], "standard_charges": [ { "minimum": 44.67, "maximum": 148.99, "gross_charge": 158.5, "discounted_cash": 87.18, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 91.93, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.54, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 126.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 134.25, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.12, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 76.08, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 94.94, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 94.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 148.99, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 139.48, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 44.67, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 134.73, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 118.88, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.84, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 107.78, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 148.99, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 124.11, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.54, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 126.01, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 118.88, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 139.48, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 91.93, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.54, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TACROLIMUS 0.1 % EX OINT", "drug_information": { "unit": "30.000000", "type": "GR" }, "code_information": [ { "code": "45802070000", "type": "NDC" } ], "standard_charges": [ { "minimum": 54.85, "maximum": 182.95, "gross_charge": 194.63, "discounted_cash": 107.05, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 112.89, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 106.27, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 155.7, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 164.85, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 56.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.42, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 116.58, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 116.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 182.95, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 171.27, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.85, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 165.44, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 145.97, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 68.57, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 132.35, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 182.95, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 152.4, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 106.27, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 154.73, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 145.97, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 171.27, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 112.89, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 106.27, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TACROLIMUS 0.5 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "R0469060773", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TACROLIMUS 0.5MG/ML ORAL SUSPENSION", "drug_information": { "unit": "210.000000", "type": "UN" }, "code_information": [ { "code": "00000999997", "type": "NDC" } ], "standard_charges": [ { "minimum": 161.71, "maximum": 539.4, "gross_charge": 573.83, "discounted_cash": 315.61, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 332.82, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 313.31, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 459.06, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 486.03, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 166.98, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 275.44, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 343.72, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 343.15, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 539.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 504.97, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 161.71, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 487.76, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 430.37, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 202.16, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 390.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 539.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 449.31, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 313.31, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 456.19, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 430.37, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 504.97, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 332.82, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 313.31, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TACROLIMUS 1 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "R0469061773", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.53, "maximum": 5.1, "gross_charge": 5.43, "discounted_cash": 2.99, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.15, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.96, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.34, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.6, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.58, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.61, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.25, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.25, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.1, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.78, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.53, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.62, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.07, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.91, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.69, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.1, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.25, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.96, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.32, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.07, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.78, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.15, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.96, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TACROLIMUS 1MG/ML SUSPENSION", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "P0469065701", "type": "NDC" } ], "standard_charges": [ { "minimum": 6.29, "maximum": 20.98, "gross_charge": 22.32, "discounted_cash": 12.28, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.95, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.19, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.86, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.91, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.5, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.71, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.37, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.35, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.98, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.64, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.29, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.97, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.74, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.86, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.18, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.98, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.48, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.19, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.74, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.74, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.64, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.95, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.19, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TACROLIMUS 5 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "R5511152701", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TACROLIMUS 5 MG/ML IV SOLN", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00469301601", "type": "NDC" } ], "standard_charges": [ { "minimum": 81.22, "maximum": 270.92, "gross_charge": 288.21, "discounted_cash": 158.52, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 167.16, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 139.11, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 230.57, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 244.11, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 83.87, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 138.34, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 172.64, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 172.35, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 270.92, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 253.62, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 81.22, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 244.98, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 216.16, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 101.54, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 195.98, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 270.92, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 225.67, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 187.8, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 229.13, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 216.16, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 253.62, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 167.16, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 139.11, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "TADALAFIL (PAH) 20 MG/5ML PO SUSP", "drug_information": { "unit": "2.500000", "type": "UN" }, "code_information": [ { "code": "46287004515", "type": "NDC" } ], "standard_charges": [ { "minimum": 20.9, "maximum": 69.73, "gross_charge": 74.18, "discounted_cash": 40.8, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.02, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.5, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.34, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 62.83, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.59, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.61, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 44.43, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 44.36, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 69.73, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.28, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.9, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.05, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.64, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.13, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.44, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 69.73, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 58.08, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.5, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 58.97, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.64, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.28, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.02, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.5, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TADALAFIL 10 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "1366856730", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TADALAFIL 20 MG PO TABS (MULTI-GPI)", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "1366858130", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TADALAFIL 5 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "R3172264430", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TAGRAXOFUSP-ERZS 1000 MCG/ML IV SOLN", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "72187040101", "type": "NDC" } ], "standard_charges": [ { "minimum": 11394.0, "maximum": 87173.76, "gross_charge": 92738.04, "discounted_cash": 51005.92, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 53788.06, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 50634.97, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 74190.43, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 78549.12, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 26986.77, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 44514.26, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 55550.09, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 11394.0, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 87173.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 81609.48, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 26133.58, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 78827.33, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 69553.53, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 32671.61, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 63061.87, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87173.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 72613.89, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 50634.97, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 15189.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 69553.53, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 81609.48, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 53788.06, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 50634.97, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TALC 3 G PL POWD", "drug_information": { "unit": "3.000000", "type": "GR" }, "code_information": [ { "code": "62327033343", "type": "NDC" } ], "standard_charges": [ { "minimum": 123.29, "maximum": 1158.0, "gross_charge": 437.5, "discounted_cash": 240.63, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 253.75, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 238.88, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 379.75, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 127.31, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 210.0, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 262.06, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 261.63, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 411.25, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 385.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 123.29, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 371.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 328.13, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 154.13, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 297.5, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 411.25, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 342.56, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 238.88, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 347.81, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 328.13, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 385.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 253.75, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 238.88, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TALC 4 G PL AERP", "drug_information": { "unit": "3.000000", "type": "GR" }, "code_information": [ { "code": "63256010030", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 1158.0, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.72, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TALC 4 G PL POWD", "drug_information": { "unit": "4.000000", "type": "GR" }, "code_information": [ { "code": "62327044444", "type": "NDC" } ], "standard_charges": [ { "minimum": 138.08, "maximum": 1158.0, "gross_charge": 490.0, "discounted_cash": 269.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 284.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 267.54, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 425.32, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 142.59, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 235.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 293.51, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 293.02, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 460.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 431.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 138.08, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 416.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 367.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 172.63, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 333.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 460.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 383.67, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 267.54, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 389.55, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 367.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 431.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 284.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 267.54, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TALC 5 G PL SUSR", "drug_information": { "unit": "5.000000", "type": "GR" }, "code_information": [ { "code": "63256020005", "type": "NDC" } ], "standard_charges": [ { "minimum": 84.12, "maximum": 1158.0, "gross_charge": 298.5, "discounted_cash": 164.18, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 173.13, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 162.98, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 259.1, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.86, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 143.28, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 178.8, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 178.5, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 280.59, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 262.68, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 84.12, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 253.73, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 223.88, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 105.16, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 202.98, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 280.59, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 233.73, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 162.98, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 237.31, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 223.88, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 262.68, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 173.13, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 162.98, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TALQUETAMAB-TGVS 3 MG/1.5ML SC SOLN", "drug_information": { "unit": "1.500000", "type": "UN" }, "code_information": [ { "code": "57894046901", "type": "NDC" } ], "standard_charges": [ { "minimum": 665.27, "maximum": 2219.15, "gross_charge": 2360.8, "discounted_cash": 1298.44, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1369.26, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1289.0, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1888.64, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1999.6, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 686.99, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1133.18, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1414.12, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 1411.76, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2219.15, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2077.5, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 665.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2006.68, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1770.6, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 831.71, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1605.34, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2219.15, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1848.51, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1289.0, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1876.84, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1770.6, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2077.5, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1369.26, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1289.0, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TALQUETAMAB-TGVS 40 MG/ML SC SOLN", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "57894047001", "type": "NDC" } ], "standard_charges": [ { "minimum": 36.94, "maximum": 22147.74, "gross_charge": 23561.43, "discounted_cash": 12958.79, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 13665.63, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.94, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 18849.14, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19956.53, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6856.38, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11309.49, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 14113.3, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 11394.0, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 22147.74, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20734.06, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 6639.61, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20027.22, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17671.07, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 8300.69, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 16021.77, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 22147.74, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 18448.6, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.86, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 15189.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17671.07, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20734.06, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 13665.63, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.94, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "TAMOXIFEN CITRATE 10 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "59651029960", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TAMOXIFEN CITRATE 10 MG/5ML PO SOLN", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "51862068201", "type": "NDC" } ], "standard_charges": [ { "minimum": 29.47, "maximum": 98.31, "gross_charge": 104.59, "discounted_cash": 57.52, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.66, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 57.11, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 83.67, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.59, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.44, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 62.65, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 62.54, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 98.31, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 92.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.47, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.9, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 78.44, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.85, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 71.12, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 98.31, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 81.89, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 57.11, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 83.15, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 78.44, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 92.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.66, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 57.11, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TAMOXIFEN CITRATE 20 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "59651030030", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TAMSULOSIN HCL 0.4 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68084029901", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Tap block bi injection", "code_information": [ { "code": "64488", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 2466.83, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 4476.11, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 4476.11, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Tap block unil by injection", "code_information": [ { "code": "64486", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 1787.31, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 3243.11, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 3243.11, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TARLATAMAB-DLLE 1 MG IV SOLR", "drug_information": { "unit": "1.100000", "type": "UN" }, "code_information": [ { "code": "55513005901", "type": "NDC" } ], "standard_charges": [ { "minimum": 843.57, "maximum": 4230.0, "gross_charge": 4500.0, "discounted_cash": 2475.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2610.0, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 843.57, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3600.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3811.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1309.5, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2160.0, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2695.5, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2691.0, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4230.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3960.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1268.1, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3825.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3375.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1585.35, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3060.0, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4230.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3523.5, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1138.82, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3577.5, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3375.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3960.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2610.0, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 843.57, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "TARLATAMAB-DLLE 10 MG IV SOLR", "drug_information": { "unit": "4.200000", "type": "UN" }, "code_information": [ { "code": "55513007701", "type": "NDC" } ], "standard_charges": [ { "minimum": 11394.0, "maximum": 42300.0, "gross_charge": 45000.0, "discounted_cash": 24750.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 26100.0, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 24570.0, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 36000.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38115.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13095.0, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21600.0, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 26955.0, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 11394.0, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42300.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39600.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 12681.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38250.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33750.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 15853.5, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 30600.0, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 42300.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 35235.0, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24570.0, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 15189.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33750.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39600.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 26100.0, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24570.0, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Tas congenital car anomal", "code_information": [ { "code": "33741", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 32059.86, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 58173.18, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 58173.18, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Tcat impl wrls p-art prs snr", "code_information": [ { "code": "33289", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 20954.52, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 15521.87, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 57251.1, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 103883.11, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 20954.52, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": 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"PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 69978.52, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4202.59, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 69978.52, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TEBENTAFUSP-TEBN 100 MCG/0.5ML IV SOLN", "drug_information": { "unit": "0.500000", "type": "UN" }, "code_information": [ { "code": "80446040101", "type": "NDC" } ], "standard_charges": [ { "minimum": 11394.0, "maximum": 52903.2, "gross_charge": 56280.0, "discounted_cash": 30954.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 32642.4, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 30728.88, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 45024.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 47669.16, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16377.48, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 27014.4, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 33711.72, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 11394.0, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52903.2, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 49526.4, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 15859.7, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 47838.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42210.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 19827.44, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 38270.4, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 52903.2, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 44067.24, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 30728.88, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 15189.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42210.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 49526.4, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 32642.4, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 30728.88, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TECHNET TC 99M PERTECHNETATE CO KIT", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "11994009011", "type": "NDC" } ], "standard_charges": [ { "minimum": 149.13, "maximum": 497.45, "gross_charge": 529.2, "discounted_cash": 291.06, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 306.94, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 288.94, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 423.36, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 448.23, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 154.0, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 254.02, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 316.99, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 316.46, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 497.45, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 465.7, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 149.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 449.82, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 396.9, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 186.44, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 359.86, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 497.45, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 414.36, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 288.94, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 420.71, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 396.9, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 465.7, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 306.94, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 288.94, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TECHNET TC 99M SULFUR COLLOID CO KIT", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "45567003001", "type": "NDC" } ], "standard_charges": [ { "minimum": 125.33, "maximum": 418.07, "gross_charge": 444.75, "discounted_cash": 244.61, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 257.96, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 242.83, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 355.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 376.7, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 129.42, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 213.48, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 266.41, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 265.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 418.07, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 391.38, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 125.33, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 378.04, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 333.56, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 156.69, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 302.43, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 418.07, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 348.24, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 242.83, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 353.58, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 333.56, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 391.38, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 257.96, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 242.83, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TECHNETIUM TC 99M ALBUMIN AGGREGATED", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "65174027030", "type": "NDC" } ], "standard_charges": [ { "minimum": 122.79, "maximum": 409.61, "gross_charge": 435.75, "discounted_cash": 239.66, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 252.74, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 237.92, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 348.6, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 369.08, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 126.8, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 209.16, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 261.01, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 260.58, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 409.61, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 383.46, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 122.79, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 370.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 326.81, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 153.51, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 296.31, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 409.61, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 341.19, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 237.92, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 346.42, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 326.81, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 383.46, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 252.74, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 237.92, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TECHNETIUM TC 99M BICISATE IV KIT", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "11994000602", "type": "NDC" } ], "standard_charges": [ { "minimum": 373.35, "maximum": 4019.21, "gross_charge": 4275.75, "discounted_cash": 2351.66, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2479.94, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 373.35, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3420.6, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3621.56, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1244.24, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2052.36, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2561.17, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2556.9, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4019.21, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3762.66, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1204.91, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3634.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3206.81, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1506.35, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2907.51, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4019.21, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3347.91, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 504.03, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3399.22, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3206.81, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3762.66, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2479.94, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 373.35, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "TECHNETIUM TC 99M MEBROFENIN IV KIT", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "45567045501", "type": "NDC" } ], "standard_charges": [ { "minimum": 44.6, "maximum": 148.78, "gross_charge": 158.28, "discounted_cash": 87.05, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 91.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.42, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 126.62, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 134.06, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.06, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.97, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 94.81, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 94.65, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 148.78, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 139.29, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 44.6, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 134.54, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 118.71, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.76, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 107.63, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 148.78, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 123.93, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.42, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 125.83, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 118.71, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 139.29, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 91.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.42, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TECHNETIUM TC 99M MEDRONATE IV KIT", "drug_information": { "unit": "2.000000", "type": "UN" }, "code_information": [ { "code": "65174066030", "type": "NDC" } ], "standard_charges": [ { "minimum": 204.69, "maximum": 682.78, "gross_charge": 726.36, "discounted_cash": 399.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 421.29, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 396.59, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 581.09, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 615.23, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 211.37, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 348.65, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 435.09, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 434.36, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 682.78, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 639.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 204.69, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 617.41, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 544.77, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 255.9, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 493.92, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 682.78, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 568.74, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 396.59, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 577.46, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 544.77, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 639.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 421.29, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 396.59, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TECHNETIUM TC 99M MERTIATIDE", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00019909620", "type": "NDC" } ], "standard_charges": [ { "minimum": 222.76, "maximum": 743.07, "gross_charge": 790.5, "discounted_cash": 434.78, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 458.49, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 431.61, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 632.4, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 669.55, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 230.04, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 379.44, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 473.51, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 472.72, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 743.07, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 695.64, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 222.76, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 671.93, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 592.88, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 278.49, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 537.54, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 743.07, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 618.96, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 431.61, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 628.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 592.88, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 695.64, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 458.49, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 431.61, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TECHNETIUM TC 99M PENTETATE AEROSOL", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "08252000193", "type": "NDC" } ], "standard_charges": [ { "minimum": 119.34, "maximum": 398.07, "gross_charge": 423.48, "discounted_cash": 232.91, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 245.62, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 231.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 338.78, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 358.69, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 123.23, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 203.27, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 253.66, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 253.24, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 398.07, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 372.66, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 119.34, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 359.96, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 317.61, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 149.19, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 287.97, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 398.07, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 331.58, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 231.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 336.67, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 317.61, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 372.66, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 245.62, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 231.22, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TECHNETIUM TC 99M PENTETATE IV KIT", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "65174028830", "type": "NDC" } ], "standard_charges": [ { "minimum": 203.38, "maximum": 678.41, "gross_charge": 721.71, "discounted_cash": 396.94, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 418.59, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 394.05, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 577.37, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 611.29, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 210.02, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 346.42, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 432.3, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 431.58, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 678.41, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 635.1, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 203.38, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 613.45, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 541.28, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 254.26, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 490.76, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 678.41, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 565.1, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 394.05, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 573.76, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 541.28, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 635.1, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 418.59, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 394.05, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TECHNETIUM TC 99M PYROPHOS IV KIT", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "45567006002", "type": "NDC" } ], "standard_charges": [ { "minimum": 47.24, "maximum": 157.58, "gross_charge": 167.64, "discounted_cash": 92.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 97.23, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 91.53, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 134.11, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 141.99, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 48.78, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 80.47, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 100.42, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 100.25, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 157.58, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 147.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.24, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 142.49, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 125.73, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.06, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 114.0, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 157.58, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 131.26, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 91.53, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 133.27, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 125.73, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 147.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 97.23, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 91.53, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TECHNETIUM TC 99M SESTAMIBI - CARDIOLITE", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "45548014110", "type": "NDC" } ], "standard_charges": [ { "minimum": 38.42, "maximum": 128.17, "gross_charge": 136.35, "discounted_cash": 74.99, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 79.08, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.45, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 109.08, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 115.49, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.68, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.45, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 81.67, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 81.54, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 128.17, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 119.99, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.42, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 115.9, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 102.26, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 48.04, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 92.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 128.17, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 106.76, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.45, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 108.4, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 102.26, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 119.99, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 79.08, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.45, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TECHNETIUM TC 99M SUCCIMER IV KIT", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "17156052501", "type": "NDC" } ], "standard_charges": [ { "minimum": 803.13, "maximum": 2679.0, "gross_charge": 2850.0, "discounted_cash": 1567.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1653.0, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1556.1, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2280.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2413.95, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 829.35, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1368.0, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1707.15, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 1704.3, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2679.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2508.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 803.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2422.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2137.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1004.06, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1938.0, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2679.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2231.55, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1556.1, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2265.75, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2137.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2508.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1653.0, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1556.1, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TECHNETIUM TC 99M TETROFOSMIN IV KIT", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "17156002630", "type": "NDC" } ], "standard_charges": [ { "minimum": 27.32, "maximum": 91.14, "gross_charge": 96.96, "discounted_cash": 53.33, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 56.24, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.94, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 77.57, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.13, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.22, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.54, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 58.08, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 57.98, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 91.14, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 85.32, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.32, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.42, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 72.72, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.16, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.93, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 91.14, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.92, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.94, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 77.08, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 72.72, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 85.32, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 56.24, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.94, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TECHNETIUM TC 99M TILMANOCEPT IJ KIT", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "65857045005", "type": "NDC" } ], "standard_charges": [ { "minimum": 531.25, "maximum": 1772.09, "gross_charge": 1885.2, "discounted_cash": 1036.86, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1093.42, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1029.32, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1508.16, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1596.76, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 548.59, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 904.9, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1129.23, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 1127.35, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1772.09, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1658.98, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 531.25, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1602.42, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1413.9, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 664.16, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1281.94, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1772.09, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1476.11, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1029.32, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1498.73, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1413.9, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1658.98, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1093.42, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1029.32, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TECHNETIUM TC 99M-LABELED RED BLOOD CELLS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00019906820", "type": "NDC" } ], "standard_charges": [ { "minimum": 119.03, "maximum": 397.06, "gross_charge": 422.4, "discounted_cash": 232.32, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 244.99, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 230.63, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 337.92, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 357.77, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 122.92, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 202.75, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 253.02, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 252.6, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 397.06, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 371.71, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 119.03, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 359.04, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 316.8, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 148.81, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 287.23, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 397.06, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 330.74, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 230.63, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 335.81, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 316.8, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 371.71, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 244.99, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 230.63, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TECHNETIUM TC 99M-WBC", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "17156002205", "type": "NDC" } ], "standard_charges": [ { "minimum": 568.01, "maximum": 5522.27, "gross_charge": 5874.75, "discounted_cash": 3231.11, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3407.36, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 568.01, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4699.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4975.91, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1709.55, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2819.88, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3518.98, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 3513.1, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5522.27, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5169.78, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1655.5, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4993.54, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4406.06, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2069.67, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3994.83, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5522.27, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4599.93, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 766.82, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4670.43, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4406.06, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5169.78, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3407.36, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 568.01, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "TECLISTAMAB-CQYV 153 MG/1.7ML SC SOLN", "drug_information": { "unit": "1.700000", "type": "UN" }, "code_information": [ { "code": "57894045001", "type": "NDC" } ], "standard_charges": [ { "minimum": 17.46, "maximum": 20071.27, "gross_charge": 21352.41, "discounted_cash": 11743.83, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 12384.4, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.46, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17081.93, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 18085.49, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6213.55, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10249.16, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 12790.09, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 11394.0, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20071.27, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 18790.12, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 6017.11, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 18149.55, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16014.31, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 7522.45, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 14519.64, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 20071.27, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 16718.94, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.57, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 15189.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16014.31, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 18790.12, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 12384.4, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.46, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "TECLISTAMAB-CQYV 30 MG/3ML SC SOLN", "drug_information": { "unit": "3.000000", "type": "UN" }, "code_information": [ { "code": "57894044901", "type": "NDC" } ], "standard_charges": [ { "minimum": 17.46, "maximum": 3973.41, "gross_charge": 4227.03, "discounted_cash": 2324.87, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2451.68, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.46, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3381.62, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3580.29, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1230.07, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2028.97, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2531.99, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2527.76, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3973.41, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3719.79, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1191.18, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3592.98, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3170.27, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1489.18, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2874.38, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3973.41, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3309.76, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.57, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3360.49, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3170.27, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3719.79, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2451.68, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.46, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "TEDIZOLID PHOSPHATE 200 MG IV SOLR", "drug_information": { "unit": "4.000000", "type": "UN" }, "code_information": [ { "code": "67919004002", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.99, "maximum": 1190.2, "gross_charge": 1266.17, "discounted_cash": 696.39, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 734.38, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.99, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1012.94, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1072.45, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 368.46, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 607.76, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 758.44, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 757.17, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1190.2, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1114.23, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 356.81, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1076.24, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 949.63, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 446.07, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 861.0, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1190.2, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 991.41, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.33, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1006.61, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 949.63, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1114.23, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 734.38, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.99, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "TEDIZOLID PHOSPHATE 200 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "72000031006", "type": "NDC" } ], "standard_charges": [ { "minimum": 430.68, "maximum": 1436.63, "gross_charge": 1528.33, "discounted_cash": 840.58, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 886.43, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 834.47, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1222.66, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1294.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 444.74, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 733.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 915.47, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 913.94, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1436.63, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1344.93, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 430.68, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1299.08, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1146.25, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 538.43, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1039.26, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1436.63, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1196.68, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 834.47, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1215.02, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1146.25, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1344.93, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 886.43, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 834.47, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TELMISARTAN 20 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68382047178", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TELMISARTAN 40 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68382047278", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TELMISARTAN 80 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68382047378", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TELMISARTAN-HCTZ 40-12.5 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00597004337", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.98, "maximum": 9.95, "gross_charge": 10.59, "discounted_cash": 5.82, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.14, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.78, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.47, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.97, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.08, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.08, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.34, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.33, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.95, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.32, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.98, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.94, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.73, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.95, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.29, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.78, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.42, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.94, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.32, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.14, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.78, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TELMISARTAN-HCTZ 80-12.5 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00597004437", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.98, "maximum": 9.95, "gross_charge": 10.59, "discounted_cash": 5.82, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.14, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.78, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.47, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.97, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.08, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.08, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.34, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.33, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.95, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.32, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.98, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.94, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.73, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.95, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.29, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.78, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.42, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.94, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.32, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.14, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.78, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TELMISARTAN-HCTZ 80-25 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00597004237", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.98, "maximum": 9.95, "gross_charge": 10.59, "discounted_cash": 5.82, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.14, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.78, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.47, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.97, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.08, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.08, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.34, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.33, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.95, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.32, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.98, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.94, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.73, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.95, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.29, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.78, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.42, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.94, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.32, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.14, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.78, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TEMAZEPAM 15 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "R6787714601", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.25, "maximum": 7.52, "gross_charge": 8.0, "discounted_cash": 4.4, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.4, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.78, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.33, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.84, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.79, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.25, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.8, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.82, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.44, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.26, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.36, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TEMAZEPAM 30 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "R6787714701", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.25, "maximum": 7.52, "gross_charge": 8.0, "discounted_cash": 4.4, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.4, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.78, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.33, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.84, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.79, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.25, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.8, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.82, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.44, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.26, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.36, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TEMAZEPAM 7.5 MG PO CAPS", "drug_information": { "unit": "2.000000", "type": "UN" }, "code_information": [ { "code": "68084054921", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.64, "maximum": 8.82, "gross_charge": 9.38, "discounted_cash": 5.16, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.44, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.12, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.5, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.94, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.73, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.5, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.62, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.61, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.82, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.25, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.64, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.97, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.3, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.38, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.82, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.34, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.12, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.46, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.25, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.44, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.12, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TEMOZOLOMIDE 10 MG/ML SUSPENSION", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "P0781269375", "type": "NDC" } ], "standard_charges": [ { "minimum": 158.02, "maximum": 527.12, "gross_charge": 560.77, "discounted_cash": 308.42, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 325.25, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 306.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 448.62, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 474.97, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 163.18, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 269.17, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 335.9, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 335.34, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 527.12, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 493.48, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 158.02, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 476.65, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 420.58, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 197.56, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 381.32, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 527.12, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 439.08, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 306.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 445.81, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 420.58, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 493.48, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 325.25, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 306.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TEMOZOLOMIDE 100 MG IV SOLR", "drug_information": { "unit": "100.000000", "type": "ME" }, "code_information": [ { "code": "00085138101", "type": "NDC" } ], "standard_charges": [ { "minimum": 5.68, "maximum": 3416.04, "gross_charge": 3634.08, "discounted_cash": 1998.74, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2107.77, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.68, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2907.26, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3078.07, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1057.52, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1744.36, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2176.81, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2173.18, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3416.04, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3197.99, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1024.08, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3088.97, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2725.56, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1280.29, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2471.17, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3416.04, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2845.48, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.67, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2889.09, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2725.56, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3197.99, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2107.77, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.68, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "TEMOZOLOMIDE 100 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "47335089274", "type": "NDC" } ], "standard_charges": [ { "minimum": 15.94, "maximum": 53.19, "gross_charge": 56.58, "discounted_cash": 31.12, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.82, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.89, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.26, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.92, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.46, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.16, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.83, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 53.19, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.79, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.94, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 48.09, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.44, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.93, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.47, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 53.19, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 44.3, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.89, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 44.98, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.44, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.79, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.82, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.89, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TEMOZOLOMIDE 140 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "47335092974", "type": "NDC" } ], "standard_charges": [ { "minimum": 23.1, "maximum": 77.05, "gross_charge": 81.97, "discounted_cash": 45.08, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.54, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 44.76, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.58, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 69.43, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.85, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.35, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.1, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.02, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 77.05, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 72.13, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.1, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 69.67, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.48, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.88, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.74, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 77.05, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 64.18, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 44.76, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.17, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.48, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 72.13, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.54, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 44.76, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TEMOZOLOMIDE 20 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "47335089174", "type": "NDC" } ], "standard_charges": [ { "minimum": 3.82, "maximum": 12.73, "gross_charge": 13.54, "discounted_cash": 7.45, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.85, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.39, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.83, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.47, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.94, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.5, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.11, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.1, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.73, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.92, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.82, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.51, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.16, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.77, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.21, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.73, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.6, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.39, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.76, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.16, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.92, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.85, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.39, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TEMOZOLOMIDE 5 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "67877053707", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TEMOZOLOMIDE CHEMO INFUSION", "drug_information": { "unit": "40.000000", "type": "UN" }, "code_information": [ { "code": "00085138101_3", "type": "NDC" } ], "standard_charges": [ { 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"percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3259.59, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1043.81, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3148.47, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2778.06, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", 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schedule" } ], "additional_generic_notes": "" } ] }, { "description": "TEMOZOLOMIDE CHEMO INFUSION|DISCARDED DRUG NOT ADMINISTERED", "drug_information": { "unit": "40.000000", "type": "UN" }, "code_information": [ { "code": "00085138101_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 5.68, "maximum": 3416.04, "gross_charge": 3634.08, "discounted_cash": 1998.74, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2107.77, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.68, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2907.26, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3078.07, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1057.52, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1744.36, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2176.81, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2173.18, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3416.04, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3197.99, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1024.08, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3088.97, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2725.56, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1280.29, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2471.17, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3416.04, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2845.48, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.67, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2889.09, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2725.56, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3197.99, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2107.77, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.68, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "Temporal artery procedure", "code_information": [ { "code": "37609", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1194.28, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 884.65, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 6195.04, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 11241.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1194.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 11241.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TEMSIROLIMUS 25 MG/ML IV SOLN", "drug_information": { "unit": "2.500000", "type": "UN" }, "code_information": [ { "code": "72611078502", "type": "NDC" } ], "standard_charges": [ { "minimum": 17.59, "maximum": 2255.47, "gross_charge": 2399.44, "discounted_cash": 1319.69, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1391.68, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.59, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1919.55, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2032.33, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 698.24, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1151.73, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1437.26, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 1434.87, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2255.47, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2111.51, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 676.16, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2039.52, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1799.58, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 845.32, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1631.62, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2255.47, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1878.76, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.74, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1907.55, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1799.58, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2111.51, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1391.68, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.59, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "Tendon excision palm/finger", "code_information": [ { "code": "26145", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1179.66, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 873.82, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 11959.67, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 21701.01, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1179.66, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 21701.01, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Tendon lengthening", "code_information": [ { "code": "26476", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2391.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1771.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 5738.72, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 10413.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2391.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 10413.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Tendon lngth upr a/e ea tdn", "code_information": [ { "code": "24305", "type": "HCPCS" } ], "standard_charges": [ { 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schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 57803.12, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Tendon shortening", "code_information": [ { "code": "26477", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2391.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1771.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 8570.36, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 15551.1, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2391.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 15551.1, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Tendon transfer with graft", "code_information": [ { "code": "26492", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2391.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1771.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 7696.42, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 13965.3, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2391.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 13965.3, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TENECTEPLASE 50 MG IV KIT (STEMI)", "drug_information": { "unit": "6.000000", "type": "UN" }, "code_information": [ { "code": "50242012047", "type": "NDC" } ], "standard_charges": [ { "minimum": 86.12, "maximum": 19992.28, "gross_charge": 21268.38, "discounted_cash": 11697.61, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 12335.66, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.12, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17014.7, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 18014.32, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6189.1, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10208.82, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 12739.76, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 11394.0, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19992.28, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 18716.17, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 5993.43, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 18078.12, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15951.29, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 7492.85, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 14462.5, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 19992.28, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 16653.14, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 116.26, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 15189.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15951.29, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 18716.17, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 12335.66, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.12, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "TENECTEPLASE 50 MG IV KIT (STROKE)", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "50242012047_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 86.12, "maximum": 19992.28, "gross_charge": 21268.38, "discounted_cash": 11697.61, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 12335.66, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.12, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17014.7, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 18014.32, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6189.1, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10208.82, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 12739.76, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 11394.0, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19992.28, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 18716.17, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 5993.43, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 18078.12, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15951.29, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 7492.85, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 14462.5, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 19992.28, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 16653.14, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 116.26, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 15189.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15951.29, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 18716.17, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 12335.66, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.12, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "TENECTEPLASE 50MG IV AND SUPPLY STROKE KIT", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "00000198888", "type": "NDC" } ], "standard_charges": [ { "minimum": 5978.87, "maximum": 19943.72, "gross_charge": 21216.72, "discounted_cash": 11669.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 12305.7, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 11584.33, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16973.38, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17970.56, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6174.07, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10184.03, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 12708.82, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 11394.0, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19943.72, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 18670.71, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 5978.87, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 18034.21, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15912.54, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 7474.65, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 14427.37, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 19943.72, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 16612.69, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 11584.33, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 15189.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15912.54, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 18670.71, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 12305.7, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 11584.33, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Tenodesis biceps tdn at elbw", "code_information": [ { "code": "24340", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 5265.64, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3900.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 5016.54, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 9102.6, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5265.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 9102.6, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TENOFOVIR ALAFENAMIDE FUMARATE 25 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "61958230101", "type": "NDC" } ], "standard_charges": [ { "minimum": 32.84, "maximum": 109.54, "gross_charge": 116.53, "discounted_cash": 64.09, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 67.59, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.63, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.22, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 98.7, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.91, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.93, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 69.8, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 69.68, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 109.54, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 102.55, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.84, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 99.05, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.4, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.05, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 79.24, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 109.54, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 91.24, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.63, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 92.64, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.4, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 102.55, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 67.59, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.63, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TENOFOVIR DISOPROXIL FUMARATE 300 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "69097053302", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TEPLIZUMAB-MZWV 2 MG/2ML IV SOLN", "drug_information": { "unit": "2.000000", "type": "UN" }, "code_information": [ { "code": "73650031614", "type": "NDC" } ], "standard_charges": [ { "minimum": 11394.0, "maximum": 40236.52, "gross_charge": 42804.81, "discounted_cash": 23542.65, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 24826.79, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23371.43, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34243.85, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 36255.67, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12456.2, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20546.31, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 25640.08, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 11394.0, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 40236.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37668.23, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 12062.4, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 36384.09, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32103.61, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 15080.13, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 29107.27, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 40236.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 33516.17, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23371.43, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 15189.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32103.61, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37668.23, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24826.79, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23371.43, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TERAZOSIN HCL 1 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "50268076415", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TERAZOSIN HCL 10 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "50268076715", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TERAZOSIN HCL 2 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "50268076515", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TERAZOSIN HCL 5 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "50268076615", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TERBINAFINE 25 MG/ML SUSPENSION (PTL)", "drug_information": { "unit": "100.000000", "type": "UN" }, "code_information": [ { "code": "08252000415", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TERBINAFINE HCL 1 % EX CREA", "drug_information": { "unit": "30.000000", "type": "GR" }, "code_information": [ { "code": "51672208002", "type": "NDC" } ], "standard_charges": [ { "minimum": 5.28, "maximum": 17.61, "gross_charge": 18.73, "discounted_cash": 10.3, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.86, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.23, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.98, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.86, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.45, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.99, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.22, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.2, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.61, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.48, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.28, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.92, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.05, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.6, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.74, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.61, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.67, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.23, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.89, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.05, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.48, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.86, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.23, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TERBINAFINE HCL 250 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "1671450101", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TERBUTALINE SULFATE 1 MG/ML IJ SOLN", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "63323066501", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TERBUTALINE SULFATE 2.5 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "1013557901", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.35, "maximum": 4.5, "gross_charge": 4.79, "discounted_cash": 2.63, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.78, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.62, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.83, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.06, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.39, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.3, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.87, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.86, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.5, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.22, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.35, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.07, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.59, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.69, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.26, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.5, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.75, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.62, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.81, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.59, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.22, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.78, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.62, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TERBUTALINE SULFATE 5 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "1013558001", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TERCONAZOLE 0.4 % VA CREA", "drug_information": { "unit": "45.000000", "type": "GR" }, "code_information": [ { "code": "51672130406", "type": "NDC" } ], "standard_charges": [ { "minimum": 22.98, "maximum": 76.66, "gross_charge": 81.55, "discounted_cash": 44.85, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.3, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 44.53, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.24, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": 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"methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.73, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.45, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 76.66, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.85, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 44.53, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 64.83, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.16, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 71.76, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.3, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 44.53, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TERCONAZOLE 0.8 % VA CREA", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "51672130200", "type": "NDC" } ], "standard_charges": [ { "minimum": 14.93, "maximum": 49.8, "gross_charge": 52.98, "discounted_cash": 29.14, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.73, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.93, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.38, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 44.87, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.42, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.43, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.74, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.68, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.62, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.93, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.03, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.74, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.66, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.03, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", 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}, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.73, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.93, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TERIPARATIDE 600 MCG/2.4ML SC SOPN", "drug_information": { "unit": "4.800000", "type": "UN" }, "code_information": [ { "code": "00002840001", "type": "NDC" } ], "standard_charges": [ { "minimum": 6788.35, "maximum": 22643.88, "gross_charge": 24089.23, "discounted_cash": 13249.08, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 13971.75, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 13152.72, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19271.38, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20403.58, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7009.97, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11562.83, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 14429.45, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 11394.0, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 22643.88, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21198.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 6788.35, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20475.85, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 18066.92, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 8486.64, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 16380.68, 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"additional_payer_notes": "N/A", "standard_charge_dollar": 18066.92, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21198.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 13971.75, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 13152.72, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TERLIPRESSIN ACETATE 0.85 MG IV SOLR", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "43825020001", "type": "NDC" } ], "standard_charges": [ { "minimum": 963.76, "maximum": 3214.8, "gross_charge": 3420.0, "discounted_cash": 1881.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1983.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1867.32, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2736.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2896.74, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 995.22, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1641.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2048.58, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2045.16, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3214.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3009.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 963.76, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2907.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2565.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1204.87, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2325.6, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3214.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2677.86, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1867.32, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2718.9, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2565.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3009.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1983.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1867.32, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TESTOSTERONE 20.25 MG/ACT (1.62%) TD GEL", "drug_information": { "unit": "75.000000", "type": "GR" }, "code_information": [ { "code": "00051846233", "type": "NDC" } ], "standard_charges": [ { "minimum": 395.59, "maximum": 1319.55, "gross_charge": 1403.78, "discounted_cash": 772.08, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 814.19, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 766.46, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1123.02, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1189.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 408.5, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 673.81, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 840.86, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 839.46, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1319.55, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1235.33, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 395.59, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1193.21, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1052.84, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 494.55, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 954.57, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1319.55, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1099.16, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 766.46, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1116.01, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1052.84, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1235.33, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 814.19, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 766.46, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TESTOSTERONE 50 MG/5GM (1%) TD GEL", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00832112035", "type": "NDC" } ], "standard_charges": [ { "minimum": 3.08, "maximum": 10.26, "gross_charge": 10.92, "discounted_cash": 6.01, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.33, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.96, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.74, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.25, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.24, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.54, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.53, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.26, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.61, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.08, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.28, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.19, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.85, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.43, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.26, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.55, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.96, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.68, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.19, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.61, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.33, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.96, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TESTOSTERONE CYPIONATE 100 MG/ML IM SOLN", "drug_information": { "unit": "0.500000", "type": "UN" }, "code_information": [ { "code": "00009034702", "type": "NDC" } ], "standard_charges": [ { "minimum": 12.68, "maximum": 42.3, "gross_charge": 45.0, "discounted_cash": 24.75, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.1, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.12, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.1, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.91, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.3, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.68, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.25, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.85, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.6, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.3, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.24, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.78, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.1, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TESTOSTERONE CYPIONATE 200 MG/ML IM SOLN", "drug_information": { "unit": "0.250000", "type": "UN" }, "code_information": [ { "code": "00143965901", "type": "NDC" } ], "standard_charges": [ { "minimum": 12.68, "maximum": 42.3, "gross_charge": 45.0, "discounted_cash": 24.75, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.1, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.12, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.1, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.91, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.3, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.68, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.25, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.85, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.6, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.3, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.24, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.78, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.1, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TETANUS IMMUNE GLOBULIN 250 UNIT/ML IM SOSY", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "13533063402", "type": "NDC" } ], "standard_charges": [ { "minimum": 317.65, "maximum": 1954.67, "gross_charge": 2079.44, "discounted_cash": 1143.69, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1206.08, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 317.65, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1663.55, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1761.29, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 605.12, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 998.13, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1245.58, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 1243.51, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1954.67, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1829.91, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 585.99, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1767.52, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1559.58, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 732.59, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1414.02, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1954.67, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1628.2, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 428.83, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1653.15, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1559.58, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1829.91, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1206.08, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 317.65, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "TETANUS-DIPHTH-ACELL PERTUSSIS 5-2-15.5 LF-MCG/0.5 IM SUSP", "drug_information": { "unit": "0.500000", "type": "UN" }, "code_information": [ { "code": "49281040020", "type": "NDC" } ], "standard_charges": [ { "minimum": 30.63, "maximum": 102.18, "gross_charge": 108.7, "discounted_cash": 59.79, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.05, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.35, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.96, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 92.07, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.63, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.18, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.11, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.0, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 102.18, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 95.66, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.63, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 92.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 81.53, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.3, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 73.92, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 102.18, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 85.11, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.35, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.42, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 81.53, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 95.66, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.05, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.35, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TETANUS-DIPHTH-ACELL PERTUSSIS 5-2.5-18.5 LF-MCG/0.5 IM SUSY", "drug_information": { "unit": "0.500000", "type": "UN" }, "code_information": [ { "code": "58160084252", "type": "NDC" } ], "standard_charges": [ { "minimum": 24.26, "maximum": 80.93, "gross_charge": 86.1, "discounted_cash": 47.36, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.94, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.01, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 68.88, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 72.93, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.06, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.33, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 51.57, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 51.49, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 80.93, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.77, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.26, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 73.19, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 64.58, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.33, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 58.55, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 80.93, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 67.42, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.01, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 68.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 64.58, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.77, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.94, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.01, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TETANUS-DIPHTHERIA TOXOIDS TD 5-2 LFU IM INJ", "drug_information": { "unit": "0.500000", "type": "UN" }, "code_information": [ { "code": "49281021510", "type": "NDC" } ], "standard_charges": [ { "minimum": 23.77, "maximum": 79.28, "gross_charge": 84.34, "discounted_cash": 46.39, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 48.92, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.05, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 67.47, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 71.44, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.54, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.48, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.52, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.44, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 79.28, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.22, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.77, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 71.69, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.26, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.71, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 57.35, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 79.28, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 66.04, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.05, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 67.05, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.26, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.22, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 48.92, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.05, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TETRABENAZINE 12.5 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "47335027723", "type": "NDC" } ], "standard_charges": [ { "minimum": 8.35, "maximum": 27.84, "gross_charge": 29.62, "discounted_cash": 16.29, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.18, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.17, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.7, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.09, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.62, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.22, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.74, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.71, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.84, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.07, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.35, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.18, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.22, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.44, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.14, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.84, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.19, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.17, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.55, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.22, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.07, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.18, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.17, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TETRACAINE HCL 0.5 % OP SOLN", "drug_information": { "unit": "4.000000", "type": "UN" }, "code_information": [ { "code": "00065074114", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TETRACAINE HCL 0.5% OP SOLN (BULK CHARGE)", "drug_information": { "unit": "4.000000", "type": "UN" }, "code_information": [ { "code": "00065074114_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TETRACAINE HCL 1 % IJ SOLN", "drug_information": { "unit": "2.000000", "type": "UN" }, "code_information": [ { "code": "54288012710", "type": "NDC" } ], "standard_charges": [ { "minimum": 23.93, "maximum": 1158.0, "gross_charge": 84.91, "discounted_cash": 46.7, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.25, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.36, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 73.7, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.71, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.76, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.86, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 79.82, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.72, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.93, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 72.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.68, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.91, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 57.74, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 79.82, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 66.48, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.36, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 67.5, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.68, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.72, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.25, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.36, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TETRACAINE-COCAINE-EPINEPHRINE TOPICAL GEL", "drug_information": { "unit": "2.000000", "type": "UN" }, "code_information": [ { "code": "P4444357802", "type": "NDC" } ], "standard_charges": [ { "minimum": 6.71, "maximum": 1158.0, "gross_charge": 23.8, "discounted_cash": 13.09, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.99, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.66, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.93, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.42, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.26, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.23, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.37, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.94, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.71, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.23, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.85, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.38, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.18, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.37, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.64, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.99, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.92, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.85, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.94, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.99, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TETRACYCLINE 25 MG/ML SUSPENSION", "drug_information": { "unit": "20.000000", "type": "UN" }, "code_information": [ { "code": "99888000061", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.47, "maximum": 4.92, "gross_charge": 5.23, "discounted_cash": 2.88, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.03, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.86, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.43, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.52, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.51, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.92, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.47, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.45, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.92, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.84, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.56, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.92, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.1, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.86, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.16, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.92, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.6, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.03, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.86, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TETRACYCLINE HCL 250 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "51991090601", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TETRACYCLINE HCL 500 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "51991090701", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TETRAHYDROZOLINE HCL 0.05 % OP SOLN", "drug_information": { "unit": "15.000000", "type": "UN" }, "code_information": [ { "code": "24385007505", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "THALLOUS CHLORIDE TL 201 1 MCI/ML IV SOLN", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "17156029918", "type": "NDC" } ], "standard_charges": [ { "minimum": 14.58, "maximum": 48.65, "gross_charge": 51.75, "discounted_cash": 28.46, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.02, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.26, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.4, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.83, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.06, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.84, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.95, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 48.65, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.54, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.58, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.99, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.81, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.23, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.19, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 48.65, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.52, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.26, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.14, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.81, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.54, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.02, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.26, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Thaw preserved stem cells", "code_information": [ { "code": "38208", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 322.25, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 238.7, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 95916.48, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 174042.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 322.25, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 174042.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "THE VERY FINEST FISH OIL PO LIQD", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "88395001540", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "THEOPHYLLINE 80 MG/15ML PO ELIX", "drug_information": { "unit": "473.000000", "type": "UN" }, "code_information": [ { "code": "70408064434", "type": "NDC" } ], "standard_charges": [ { "minimum": 200.85, "maximum": 669.97, "gross_charge": 712.73, "discounted_cash": 392.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 413.38, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 389.15, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 570.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 603.68, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 207.4, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 342.11, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 426.93, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 426.21, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 669.97, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 627.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 200.85, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 605.82, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 534.55, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 251.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 484.66, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 669.97, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 558.07, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 389.15, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 566.62, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 534.55, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 627.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 413.38, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 389.15, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "THEOPHYLLINE ER 100 MG PO CP24", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "52244010010", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.25, "maximum": 7.49, "gross_charge": 7.97, "discounted_cash": 4.38, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.62, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.35, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.38, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.75, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.83, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.77, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.77, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.49, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.01, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.25, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.77, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.98, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.81, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.42, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.49, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.24, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.35, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.34, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.98, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.01, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.62, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.35, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "THEOPHYLLINE ER 200 MG PO CP24", "drug_information": { "unit": "2.000000", "type": "UN" }, "code_information": [ { "code": "52244020010", "type": "NDC" } ], "standard_charges": [ { "minimum": 6.68, "maximum": 22.28, "gross_charge": 23.7, "discounted_cash": 13.04, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.75, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.94, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.96, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.07, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.9, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.38, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.2, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.17, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.28, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.86, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.68, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.15, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.78, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.35, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.12, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.28, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.56, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.94, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.84, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.78, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.86, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.75, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.94, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "THEOPHYLLINE ER 300 MG PO CP24", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "52244030010", "type": "NDC" } ], "standard_charges": [ { "minimum": 4.1, "maximum": 13.69, "gross_charge": 14.56, "discounted_cash": 8.01, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.44, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.95, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.65, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.33, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.24, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.99, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.72, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.71, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.69, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.81, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.1, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.38, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.92, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.13, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.9, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.69, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.4, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.95, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.58, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.92, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.81, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.44, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.95, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "THEOPHYLLINE ER 300 MG PO TB12", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "62332002531", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "THEOPHYLLINE ER 400 MG PO TB24", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68462038001", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Ther fx nasal inf turbinate", "code_information": [ { "code": "30930", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2390.47, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1770.72, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 19489.69, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 35364.37, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2390.47, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 35364.37, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Ther injection carp tunnel", "code_information": [ { "code": "20526", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 217.58, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 1322.84, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 2400.3, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 217.58, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 2400.3, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Ther spi pnxr drg csf", "code_information": [ { "code": "62272", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 510.46, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 378.12, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 6629.04, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 12028.5, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 510.46, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 12028.5, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "THERA M PLUS PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "77333086110", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "THIAMINE HCL 100 MG PO TABS (MULTI GPI)", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "77333093410", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "THIAMINE HCL 100 MG/ML IJ SOLN", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "43598005025", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "THIOGUANINE 40 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "80725063025", "type": "NDC" } ], "standard_charges": [ { "minimum": 551.94, "maximum": 1841.09, "gross_charge": 1958.61, "discounted_cash": 1077.24, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1135.99, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1069.4, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1566.89, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1658.94, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 569.96, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 940.13, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1173.21, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 1171.25, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1841.09, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1723.58, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 551.94, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1664.82, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1468.96, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 690.02, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1331.85, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1841.09, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1533.59, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1069.4, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1557.09, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1468.96, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1723.58, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1135.99, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1069.4, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "THIOGUANINE 40MG/ML SUSPENSION", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "P0173088025", "type": "NDC" } ], "standard_charges": [ { "minimum": 15.94, "maximum": 53.17, "gross_charge": 56.56, "discounted_cash": 31.11, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.88, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.25, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.91, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.46, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.15, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.82, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 53.17, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.77, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.94, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 48.08, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.42, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.93, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.46, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 53.17, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 44.29, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.88, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 44.97, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.42, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.77, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.88, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "THIOTEPA 100 MG IJ SOLR", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "71288015710", "type": "NDC" } ], "standard_charges": [ { "minimum": 114.12, "maximum": 3575.7, "gross_charge": 3803.94, "discounted_cash": 2092.17, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2206.29, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 114.12, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3043.15, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3221.94, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1106.95, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1825.89, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2278.56, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2274.76, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3575.7, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3347.47, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1071.95, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3233.35, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2852.96, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1340.13, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2586.68, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3575.7, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2978.49, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 154.07, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3024.13, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2852.96, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3347.47, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2206.29, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 114.12, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "THIOTEPA 15 MG IJ SOLR", "drug_information": { "unit": "1.500000", "type": "UN" }, "code_information": [ { "code": "71288015605", "type": "NDC" } ], "standard_charges": [ { "minimum": 114.12, "maximum": 461.89, "gross_charge": 491.37, "discounted_cash": 270.25, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 284.99, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 114.12, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 393.1, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 416.19, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 142.99, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 235.86, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 294.33, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 293.84, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 461.89, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 432.41, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 138.47, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 417.66, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 368.53, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 173.11, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 334.13, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 461.89, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 384.74, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 154.07, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 390.64, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 368.53, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 432.41, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 284.99, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 114.12, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "Thoracoscopy diagnostic", "code_information": [ { "code": "32601", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4300.51, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3185.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 28647.33, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 51981.08, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4300.51, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 51981.08, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Thoracoscopy w/ th nrv exc", "code_information": [ { "code": "32664", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 28709.3, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 52153.35, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 52153.35, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Thoracoscopy w/bx infiltrate", "code_information": [ { "code": "32607", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 7674.11, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5684.53, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 24847.36, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 45085.96, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7674.11, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 45085.96, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Thoracoscopy w/bx med space", "code_information": [ { "code": "32606", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4300.51, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3185.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 12165.94, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 22075.28, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4300.51, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 22075.28, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Thoracoscopy w/bx pleura", "code_information": [ { "code": "32609", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4300.51, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": 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billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Thoracoscopy w/mediast exc", "code_information": [ { "code": "32662", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 36177.7, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 65681.24, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 65681.24, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Thoracoscopy w/thymus resect", "code_information": [ { "code": "32673", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 28984.87, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 52593.5, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 52593.5, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Thoracoscopy w/wedge resect", "code_information": [ { "code": "32666", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 43314.6, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 82723.05, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 82723.05, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Thrmbc/nfs dialysis circuit", "code_information": [ { "code": "36904", "type": "HCPCS" }, { "code": "36905", "type": "HCPCS" }, { "code": "36906", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 13235.9, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3113.03, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 6191.95, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 9804.37, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 24403.72, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 44280.97, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4202.59, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8359.13, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 13235.9, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 44280.97, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Throat muscle surgery", "code_information": [ { "code": "43030", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4360.43, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3229.95, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 32993.45, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 59867.15, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4360.43, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 59867.15, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "THROMBIN (RECOMBINANT) 5000 UNITS EX SOLR", "drug_information": { "unit": "5000.000000", "type": "UN" }, "code_information": [ { "code": "00338032201", "type": "NDC" } ], "standard_charges": [ { "minimum": 29.45, "maximum": 98.23, "gross_charge": 104.5, "discounted_cash": 57.48, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.61, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 57.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 83.6, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.51, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.41, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.16, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 62.6, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 62.49, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 98.23, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 91.96, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.45, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.83, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 78.38, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.82, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 71.06, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 98.23, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 81.82, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 57.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 83.08, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 78.38, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 91.96, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.61, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 57.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "THROMBIN 5000 UNITS EX SOLR", "drug_information": { "unit": "5000.000000", "type": "UN" }, "code_information": [ { "code": "60793021505", "type": "NDC" } ], "standard_charges": [ { "minimum": 27.62, "maximum": 92.12, "gross_charge": 98.0, "discounted_cash": 53.9, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 56.84, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 53.51, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 78.4, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 83.01, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.52, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.04, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 58.7, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 58.6, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 92.12, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.24, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.62, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 83.3, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 73.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.53, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 66.64, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 92.12, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 76.73, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 53.51, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 77.91, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 73.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.24, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 56.84, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 53.51, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Thrombolytic art therapy", "code_information": [ { "code": "37211", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 3984.54, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2951.51, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 53545.45, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 97159.16, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3984.54, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 97159.16, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Thumb fusion with graft", "code_information": [ { "code": "26842", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 5265.64, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3900.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 21537.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 39094.74, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5265.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 39094.74, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Thumb tendon transfer", "code_information": [ { "code": "26510", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2391.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1771.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 10164.28, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 19154.27, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2391.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 19154.27, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "THYROID 180 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00456046201", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "THYROID 30 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "R0456045801", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "THYROID 60 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "R0456045901", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "THYROTROPIN ALFA 0.9 MG IM SOLR", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "58468003002", "type": "NDC" } ], "standard_charges": [ { "minimum": 1132.04, "maximum": 5854.6, "gross_charge": 6228.3, "discounted_cash": 3425.57, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3612.41, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1132.04, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4982.64, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5275.37, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1812.44, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2989.58, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3730.75, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 3724.52, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5854.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5480.9, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1755.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5294.06, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4671.23, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2194.23, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4235.24, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5854.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4876.76, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1528.26, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4951.5, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4671.23, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5480.9, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3612.41, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1132.04, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "TIAGABINE HCL 4 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00093503156", "type": "NDC" } ], "standard_charges": [ { "minimum": 4.05, "maximum": 13.51, "gross_charge": 14.37, "discounted_cash": 7.9, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.33, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.85, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.5, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.18, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.9, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.61, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.59, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.51, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.65, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.05, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.21, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.78, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.06, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.77, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.51, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.25, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.85, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.42, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.78, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.65, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.33, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.85, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Tib/per revasc w/ather", "code_information": [ { "code": "37229", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 13235.9, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 9804.37, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 27737.75, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 50330.62, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 13235.9, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 50330.62, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Tib/per revasc w/stent", "code_information": [ { "code": "37230", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 13235.9, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 9804.37, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 31688.75, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 57499.91, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 13235.9, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 57499.91, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Tib/per revasc w/tla", "code_information": [ { "code": "37228", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 8359.13, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 6191.95, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 32513.23, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 58995.84, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8359.13, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 58995.84, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TICAGRELOR 60 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "R0186077660", "type": "NDC" } ], "standard_charges": [ { "minimum": 4.15, "maximum": 13.86, "gross_charge": 14.74, "discounted_cash": 8.11, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.55, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.05, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.79, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.48, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.29, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.08, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.83, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.81, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.86, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.97, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.15, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.53, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.06, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.19, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.02, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.86, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.54, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.05, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.72, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.06, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.97, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.55, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.05, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TICAGRELOR 90 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00186077739", "type": "NDC" } ], "standard_charges": [ { "minimum": 4.77, "maximum": 15.92, "gross_charge": 16.94, "discounted_cash": 9.32, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.83, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.25, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.55, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.35, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.93, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.13, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.15, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.13, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.92, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.91, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.77, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.71, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.97, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.52, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.92, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.26, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.25, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.47, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.71, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.91, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.83, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.25, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TICK-BORNE ENCEPHALITIS VACC 1.2 MCG/0.25ML IM SUSY", "drug_information": { "unit": "0.250000", "type": "UN" }, "code_information": [ { "code": "00069029702", "type": "NDC" } ], "standard_charges": [ { "minimum": 326.25, "maximum": 1088.26, "gross_charge": 1157.72, "discounted_cash": 636.75, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 671.48, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 632.12, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 926.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 980.59, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 336.9, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 555.71, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 693.47, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 692.32, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1088.26, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1018.79, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 326.25, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 984.06, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 868.29, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 407.86, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 787.25, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1088.26, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 906.49, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 632.12, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 920.39, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 868.29, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1018.79, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 671.48, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 632.12, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TICK-BORNE ENCEPHALITIS VACC 2.4 MCG/0.5ML IM SUSY", "drug_information": { "unit": "0.500000", "type": "UN" }, "code_information": [ { "code": "00069041110", "type": "NDC" } ], "standard_charges": [ { "minimum": 326.25, "maximum": 1088.26, "gross_charge": 1157.72, "discounted_cash": 636.75, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 671.48, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 632.12, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 926.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 980.59, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 336.9, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 555.71, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 693.47, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 692.32, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1088.26, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1018.79, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 326.25, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 984.06, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 868.29, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 407.86, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 787.25, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1088.26, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 906.49, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 632.12, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 920.39, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 868.29, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1018.79, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 671.48, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 632.12, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TIGECYCLINE 50 MG IV SOLR", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "60505609801", "type": "NDC" } ], "standard_charges": [ { "minimum": 12.12, "maximum": 40.44, "gross_charge": 43.02, "discounted_cash": 23.66, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.95, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.49, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.42, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.44, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.52, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.65, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.77, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.73, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.44, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.86, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.12, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.57, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.27, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.16, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.25, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.44, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.68, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.49, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.27, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.86, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.95, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.49, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TIMOLOL MALEATE (ONCE-DAILY) 0.5 % OP SOLN", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "60505100501", "type": "NDC" } ], "standard_charges": [ { "minimum": 162.84, "maximum": 543.18, "gross_charge": 577.85, "discounted_cash": 317.82, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 335.15, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 315.51, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 462.28, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 489.44, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 168.15, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 277.37, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 346.13, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 345.55, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 543.18, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 508.51, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 162.84, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 491.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 433.39, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 203.58, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 392.94, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 543.18, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 452.46, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 315.51, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 459.39, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 433.39, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 508.51, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 335.15, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 315.51, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TIMOLOL MALEATE 0.25 % OP SOLG", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "62332054505", "type": "NDC" } ], "standard_charges": [ { "minimum": 80.49, "maximum": 268.49, "gross_charge": 285.63, "discounted_cash": 157.1, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 165.67, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 155.95, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 228.5, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 241.93, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 83.12, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 137.1, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 171.09, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 170.81, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 268.49, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 251.35, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 80.49, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 242.79, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 214.22, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 100.63, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 194.23, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 268.49, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 223.65, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 155.95, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 227.08, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 214.22, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 251.35, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 165.67, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 155.95, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TIMOLOL MALEATE 0.25 % OP SOLN", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "64980051305", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TIMOLOL MALEATE 0.5 % OP SOLG", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "62332054605", "type": "NDC" } ], "standard_charges": [ { "minimum": 152.32, "maximum": 508.11, "gross_charge": 540.54, "discounted_cash": 297.3, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 313.51, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 295.13, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 432.43, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 457.84, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 157.3, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 259.46, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 323.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 323.24, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 508.11, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 475.68, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 152.32, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 459.46, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 405.41, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 190.43, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 367.57, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 508.11, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 423.24, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 295.13, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 429.73, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 405.41, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 475.68, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 313.51, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 295.13, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TIMOLOL MALEATE 0.5 % OP SOLN", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "61314022705", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TIMOLOL MALEATE 0.5 % SOLG (OFF-LABEL TOPICAL)", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "62332054605_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 152.32, "maximum": 508.11, "gross_charge": 540.54, "discounted_cash": 297.3, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 313.51, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 295.13, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 432.43, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 457.84, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 157.3, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 259.46, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 323.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 323.24, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 508.11, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 475.68, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 152.32, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 459.46, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 405.41, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 190.43, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 367.57, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 508.11, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 423.24, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 295.13, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 429.73, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 405.41, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 475.68, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 313.51, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 295.13, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TINIDAZOLE 500 MG PO TABS", "drug_information": { "unit": "4.000000", "type": "UN" }, "code_information": [ { "code": "42799020801", "type": "NDC" } ], "standard_charges": [ { "minimum": 6.03, "maximum": 20.13, "gross_charge": 21.41, "discounted_cash": 11.78, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.42, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.69, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.13, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.13, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.23, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.28, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.82, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.8, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.13, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.84, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.03, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.2, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.06, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.54, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.56, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.13, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.76, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.69, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.02, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.06, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.84, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.42, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.69, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TIOTROPIUM BROMIDE MONOHYDRATE 18 MCG IN CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00597007575", "type": "NDC" } ], "standard_charges": [ { "minimum": 32.87, "maximum": 109.65, "gross_charge": 116.65, "discounted_cash": 64.16, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 67.66, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.69, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.32, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 98.8, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.95, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.99, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 69.87, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 69.76, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 109.65, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 102.65, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.87, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 99.15, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.49, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.1, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 79.32, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 109.65, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 91.34, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.69, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 92.74, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.49, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 102.65, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 67.66, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.69, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TIOTROPIUM BROMIDE MONOHYDRATE 2.5 MCG/ACT IN AERS", "drug_information": { "unit": "4.000000", "type": "GR" }, "code_information": [ { "code": "00597010051", "type": "NDC" } ], "standard_charges": [ { "minimum": 23.93, "maximum": 79.83, "gross_charge": 84.93, "discounted_cash": 46.71, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.26, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 67.94, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 71.94, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.71, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.77, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.87, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.79, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 79.83, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.74, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.93, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 72.19, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.7, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.92, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 57.75, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 79.83, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 66.5, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 67.52, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.7, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.74, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.26, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TIOTROPIUM BROMIDE-OLODATEROL 2.5-2.5 MCG/ACT IN AERS", "drug_information": { "unit": "4.000000", "type": "GR" }, "code_information": [ { "code": "00597015570", "type": "NDC" } ], "standard_charges": [ { "minimum": 29.99, "maximum": 100.04, "gross_charge": 106.43, "discounted_cash": 58.54, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.73, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 58.11, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 85.14, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 90.15, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.97, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 51.09, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.75, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.65, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 100.04, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.66, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.99, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 90.47, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 79.82, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.5, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 72.37, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 100.04, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 83.33, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 58.11, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 84.61, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 79.82, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.66, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.73, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 58.11, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Tis cgen car anomal 1st shnt", "code_information": [ { "code": "33745", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 55459.28, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 100631.8, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 100631.8, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Tis trnfr any 30.1-60 sq cm", "code_information": [ { "code": "14301", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2698.5, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1998.89, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 12483.13, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 22650.84, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2698.5, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 22650.84, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Tis trnfr e/n/e/l 10 sq cm/<", "code_information": [ { "code": "14060", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1348.33, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 998.76, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 6924.77, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 12565.1, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1348.33, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 12565.1, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Tis trnfr e/n/e/l10.1-30sqcm", "code_information": [ { "code": "14061", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1348.33, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 998.76, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 8454.4, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 15340.65, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1348.33, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 15340.65, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Tis trnfr f/c/c/m/n/a/g/h/f", "code_information": [ { "code": "14040", "type": "HCPCS" }, { "code": "14041", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1348.33, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 998.76, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 6887.56, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 12497.58, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1348.33, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 12497.58, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Tis trnfr s/a/l 10 sq cm/<", "code_information": [ { "code": "14020", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1348.33, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 998.76, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 43306.53, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 78656.56, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1348.33, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 78656.56, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Tis trnfr s/a/l 10.1-30 sqcm", "code_information": [ { "code": "14021", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1348.33, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 998.76, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 7105.2, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 12892.5, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1348.33, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 12892.5, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Tis trnfr trunk 10 sq cm/<", "code_information": [ { "code": "14000", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1348.33, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 998.76, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 8154.24, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 14796.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1348.33, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 14796.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Tis trnfr trunk 10.1-30sqcm", "code_information": [ { "code": "14001", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1348.33, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 998.76, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 10285.16, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 18662.58, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1348.33, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 18662.58, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TISOTUMAB VEDOTIN-TFTV 40 MG IV SOLR", "drug_information": { "unit": "4.000000", "type": "UN" }, "code_information": [ { "code": "51144000301", "type": "NDC" } ], "standard_charges": [ { "minimum": 6021.78, "maximum": 20086.86, "gross_charge": 21369.0, "discounted_cash": 11752.95, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 12394.02, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 11667.47, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17095.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 18099.54, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6218.38, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10257.12, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 12800.03, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 11394.0, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20086.86, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 18804.72, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 6021.78, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 18163.65, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16026.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 7528.3, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 14530.92, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 20086.86, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 16731.93, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 11667.47, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 15189.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16026.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 18804.72, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 12394.02, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 11667.47, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Tiss xpndr plmt brst rcnstj", "code_information": [ { "code": "19357", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 12824.32, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 9499.5, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 54295.43, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 98519.93, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 12824.32, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 98519.93, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TIZANIDINE HCL 2 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "50268075915", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 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"standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 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"unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68084064501", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Tlh uterus 250 g or less", "code_information": [ { "code": "58570", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 7674.11, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5684.53, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 21904.43, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 39745.94, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7674.11, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 39745.94, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Tlh uterus over 250 g", "code_information": [ { "code": "58572", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 7674.11, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5684.53, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 30229.69, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 56162.61, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7674.11, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 56162.61, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Tlh w/t/o 250 g or less", "code_information": [ { "code": "58571", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 7674.11, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5684.53, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 27024.1, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 51850.74, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7674.11, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 51850.74, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Tlh w/t/o uterus over 250 g", "code_information": [ { "code": "58573", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 7674.11, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5684.53, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 36115.87, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 65532.82, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7674.11, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 65532.82, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TOBRAMYCIN 0.3 % OP OINT", "drug_information": { "unit": "4.000000", "type": "GR" }, "code_information": [ { "code": "00078081301", "type": "NDC" } ], "standard_charges": [ { "minimum": 390.17, "maximum": 1301.49, "gross_charge": 1384.56, "discounted_cash": 761.51, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 803.04, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 755.97, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1107.65, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1172.72, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 402.91, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 664.59, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 829.35, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 827.97, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1301.49, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1218.41, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 390.17, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1176.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1038.42, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 487.78, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 941.5, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1301.49, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1084.11, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 755.97, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1100.73, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1038.42, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1218.41, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 803.04, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 755.97, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TOBRAMYCIN 0.3 % OP SOLN", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "70069013101", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TOBRAMYCIN 10 MG/ML SYR <30 MG (NICU)", "drug_information": { "unit": "2.000000", "type": "UN" }, "code_information": [ { "code": "63323030502_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TOBRAMYCIN 10 MG/ML SYRINGE <=20 MG (EXTENDED)", "drug_information": { "unit": "2.000000", "type": "UN" }, "code_information": [ { "code": "63323030502_3", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TOBRAMYCIN 10 MG/ML SYRINGE <=20 MG (TRADITIONAL)", "drug_information": { "unit": "2.000000", "type": "UN" }, "code_information": [ { "code": "63323030502_4", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TOBRAMYCIN 300 MG/5 ML INHALATION (DILUTED)", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "39822041206", "type": "NDC" } ], "standard_charges": [ { "minimum": 49.26, "maximum": 164.31, "gross_charge": 174.8, "discounted_cash": 96.14, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 101.38, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 95.44, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 139.84, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 148.06, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.87, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 83.9, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 104.71, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 104.53, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 164.31, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 153.82, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.26, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 148.58, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 131.1, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.58, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 118.86, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 164.31, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 136.87, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 95.44, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 138.97, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 131.1, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 153.82, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 101.38, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 95.44, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TOBRAMYCIN 300 MG/5ML IN NEBU", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "65162091446", "type": "NDC" } ], "standard_charges": [ { "minimum": 10.82, "maximum": 36.11, "gross_charge": 38.41, "discounted_cash": 21.13, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.28, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.97, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.73, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.53, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.18, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.44, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.01, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.97, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.11, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.82, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.65, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.81, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.53, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.12, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.11, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.08, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.97, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.54, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.81, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.28, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.97, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TOBRAMYCIN 40 MG/ML SYRINGE (IM)", "drug_information": { "unit": "2.000000", "type": "UN" }, "code_information": [ { "code": "67457047322", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TOBRAMYCIN 40 MG/ML SYRINGE (IM) (NICU)", "drug_information": { "unit": "2.000000", "type": "UN" }, "code_information": [ { "code": "67457047322_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TOBRAMYCIN INTRAVITREAL INJ (0.2MG/0.1ML)", "drug_information": { "unit": "0.100000", "type": "UN" }, "code_information": [ { "code": "0069008801", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TOBRAMYCIN OPHTHALMIC SOLN 15 MG/ML", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "9994001510", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 1158.0, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 95.48, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TOBRAMYCIN SUBCONJUNCTIVAL INJ (20 MG/0.5 ML)", "drug_information": { "unit": "0.500000", "type": "UN" }, "code_information": [ { "code": "08252001200", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TOBRAMYCIN SULFATE 1.2 G IJ SOLR", "drug_information": { "unit": "30.000000", "type": "UN" }, "code_information": [ { "code": "39822041206_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 49.26, "maximum": 164.31, "gross_charge": 174.8, "discounted_cash": 96.14, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 101.38, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 95.44, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 139.84, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 148.06, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.87, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 83.9, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 104.71, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 104.53, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 164.31, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 153.82, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.26, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 148.58, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 131.1, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.58, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 118.86, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 164.31, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 136.87, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 95.44, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 138.97, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 131.1, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 153.82, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 101.38, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 95.44, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TOBRAMYCIN SULFATE 1.2 G IJ SOLR (INTRA-ARTICULAR ONLY)", "drug_information": { "unit": "30.000000", "type": "UN" }, "code_information": [ { "code": "39822041206_3", "type": "NDC" } ], "standard_charges": [ { "minimum": 49.26, "maximum": 164.31, "gross_charge": 174.8, "discounted_cash": 96.14, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 101.38, 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"additional_payer_notes": "N/A", "standard_charge_dollar": 83.9, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 104.71, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 104.53, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 164.31, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 153.82, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.26, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 148.58, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 131.1, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.58, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 118.86, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 164.31, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 136.87, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 95.44, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 138.97, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 131.1, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 153.82, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 101.38, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 95.44, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TOBRAMYCIN SULFATE 1.2 G TOPICAL", "drug_information": { "unit": "2.000000", "type": "GR" }, "code_information": [ { "code": "39822041206_4", "type": "NDC" } ], "standard_charges": [ { "minimum": 82.1, "maximum": 1158.0, "gross_charge": 291.34, "discounted_cash": 160.24, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 168.98, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 159.07, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 252.88, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 84.78, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 139.84, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 174.51, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 174.22, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 273.86, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 256.38, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.1, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 247.64, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 218.51, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 102.64, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 198.11, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 273.86, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 228.12, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 159.07, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 231.62, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 218.51, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 256.38, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 168.98, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 159.07, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TOBRAMYCIN SULFATE 1.2 GM/30ML IJ SOLN", "drug_information": { "unit": "30.000000", "type": "UN" }, "code_information": [ { "code": "63323030630_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TOBRAMYCIN SULFATE 10 MG/ML IJ SOLN", "drug_information": { "unit": "2.000000", "type": "UN" }, "code_information": [ { "code": "63323030502", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TOBRAMYCIN SULFATE 2 GM/50ML IJ SOLN", "drug_information": { "unit": "50.000000", "type": "UN" }, "code_information": [ { "code": "63323030751", "type": "NDC" } ], "standard_charges": [ { "minimum": 29.12, "maximum": 97.15, "gross_charge": 103.35, "discounted_cash": 56.84, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.94, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 56.43, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.68, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.54, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.07, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.61, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.91, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.8, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 97.15, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 90.95, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.12, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.85, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 77.51, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 70.28, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 97.15, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 80.92, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 56.43, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.16, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 77.51, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 90.95, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.94, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 56.43, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TOBRAMYCIN SULFATE 80 MG/2ML IJ SOLN", "drug_information": { "unit": "2.000000", "type": "UN" }, "code_information": [ { "code": "63323030602", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TOBRAMYCIN SULFATE FOR INHALATION", "drug_information": { "unit": "2.000000", "type": "UN" }, "code_information": [ { "code": "63323030630", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 1158.0, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.72, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TOBRAMYCIN-DEXAMETHASONE 0.3-0.1 % OP OINT", "drug_information": { "unit": "4.000000", "type": "GR" }, "code_information": [ { "code": "00078087601", "type": "NDC" } ], "standard_charges": [ { "minimum": 553.84, "maximum": 1847.44, "gross_charge": 1965.36, "discounted_cash": 1080.95, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1139.91, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1073.09, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1572.29, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1664.66, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 571.92, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 943.37, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1177.25, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 1175.29, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1847.44, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1729.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 553.84, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1670.56, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1474.02, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 692.4, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1336.44, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1847.44, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1538.88, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1073.09, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1562.46, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1474.02, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1729.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1139.91, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1073.09, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TOBRAMYCIN-DEXAMETHASONE 0.3-0.1 % OP SUSP", "drug_information": { "unit": "2.500000", "type": "UN" }, "code_information": [ { "code": "00574403125", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TOCILIZUMAB 162 MG/0.9ML SC SOSY", "drug_information": { "unit": "0.900000", "type": "UN" }, "code_information": [ { "code": "50242013801", "type": "NDC" } ], "standard_charges": [ { "minimum": 963.39, "maximum": 3213.59, "gross_charge": 3418.71, "discounted_cash": 1880.29, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1982.85, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1866.62, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2734.97, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2895.65, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 994.84, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1640.98, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2047.81, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2044.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3213.59, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3008.46, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 963.39, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2905.9, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2564.03, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1204.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2324.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3213.59, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2676.85, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1866.62, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2717.87, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2564.03, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3008.46, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1982.85, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1866.62, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TOCILIZUMAB 200 MG/10ML IV SOLN", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "50242013601", "type": "NDC" } ], "standard_charges": [ { "minimum": 3.25, "maximum": 3632.39, "gross_charge": 3864.24, "discounted_cash": 2125.33, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2241.26, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.25, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3091.39, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3273.01, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1124.49, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1854.84, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2314.68, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2310.82, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3632.39, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3400.53, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1088.94, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3284.6, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2898.18, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1361.37, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2627.68, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3632.39, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3025.7, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.39, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3072.07, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2898.18, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3400.53, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2241.26, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.25, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "TOCILIZUMAB 400 MG/20ML IV SOLN", "drug_information": { "unit": "20.000000", "type": "UN" }, "code_information": [ { "code": "50242013701", "type": "NDC" } ], "standard_charges": [ { "minimum": 2177.88, "maximum": 7264.74, "gross_charge": 7728.45, "discounted_cash": 4250.65, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4482.5, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4219.73, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6182.76, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6546.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2248.98, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3709.66, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4629.34, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4621.61, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7264.74, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6801.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2177.88, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6569.18, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5796.34, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2722.73, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5255.35, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7264.74, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6051.38, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4219.73, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6144.12, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5796.34, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6801.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4482.5, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4219.73, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TOCILIZUMAB 80 MG/4ML IV SOLN", "drug_information": { "unit": "4.000000", "type": "UN" }, "code_information": [ { "code": "50242013501", "type": "NDC" } ], "standard_charges": [ { "minimum": 580.77, "maximum": 1937.26, "gross_charge": 2060.92, "discounted_cash": 1133.51, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1195.33, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1125.26, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1648.74, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1745.6, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 599.73, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 989.24, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1234.49, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 1232.43, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1937.26, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1813.61, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 580.77, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1751.78, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1545.69, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 726.06, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1401.43, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1937.26, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1613.7, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1125.26, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1638.43, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1545.69, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1813.61, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1195.33, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1125.26, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TOFACITINIB CITRATE 10 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00069100201", "type": "NDC" } ], "standard_charges": [ { "minimum": 73.81, "maximum": 246.21, "gross_charge": 261.93, "discounted_cash": 144.06, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 151.92, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 143.01, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 209.54, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 221.85, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 76.22, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 125.73, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 156.9, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 156.63, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 246.21, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 230.5, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 73.81, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 222.64, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 196.45, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 92.28, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 178.11, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 246.21, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 205.09, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 143.01, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 208.23, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 196.45, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 230.5, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 151.92, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 143.01, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TOFACITINIB CITRATE 5 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00069100101", "type": "NDC" } ], "standard_charges": [ { "minimum": 73.81, "maximum": 246.21, "gross_charge": 261.93, "discounted_cash": 144.06, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 151.92, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 143.01, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 209.54, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 221.85, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 76.22, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 125.73, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 156.9, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 156.63, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 246.21, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 230.5, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 73.81, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 222.64, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 196.45, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 92.28, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 178.11, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 246.21, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 205.09, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 143.01, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 208.23, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 196.45, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 230.5, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 151.92, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 143.01, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TOLCAPONE 100 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00187093801", "type": "NDC" } ], "standard_charges": [ { "minimum": 106.11, "maximum": 353.96, "gross_charge": 376.55, "discounted_cash": 207.1, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 218.4, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 205.6, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 301.24, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 318.94, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 109.58, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 180.74, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 225.55, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 225.18, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 353.96, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 331.36, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 106.11, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 320.07, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 282.41, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 132.66, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 256.05, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 353.96, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 294.84, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 205.6, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 299.36, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 282.41, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 331.36, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 218.4, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 205.6, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TOLNAFTATE 1 % EX CREA", "drug_information": { "unit": "15.000000", "type": "GR" }, "code_information": [ { "code": "00536131543", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.32, "maximum": 4.42, "gross_charge": 4.7, "discounted_cash": 2.59, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.73, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.98, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.37, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.26, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.82, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.81, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.42, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.14, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.32, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.53, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.66, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.42, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.68, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.74, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.53, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.14, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.73, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.57, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TOLNAFTATE 1 % EX POWD", "drug_information": { "unit": "45.000000", "type": "GR" }, "code_information": [ { "code": "00536132926", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TOLTERODINE TARTRATE 1 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "33342009709", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TOLTERODINE TARTRATE 2 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "33342009809", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TOLTERODINE TARTRATE ER 2 MG PO CP24", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687031921", "type": "NDC" } ], "standard_charges": [ { "minimum": 3.11, "maximum": 10.37, "gross_charge": 11.03, "discounted_cash": 6.07, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.4, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.02, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.82, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.34, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.21, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.29, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.61, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.6, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.37, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.71, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.11, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.38, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.27, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.89, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.5, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.37, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.64, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.02, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.77, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.27, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.71, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.4, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.02, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TOLTERODINE TARTRATE ER 4 MG PO CP24", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687033021", "type": "NDC" } ], "standard_charges": [ { "minimum": 3.11, "maximum": 10.37, "gross_charge": 11.03, "discounted_cash": 6.07, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.4, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.02, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.82, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.34, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.21, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.29, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.61, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.6, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.37, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.71, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.11, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.38, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.27, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.89, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.5, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.37, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.64, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.02, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.77, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.27, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.71, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.4, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.02, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TOLVAPTAN 15 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "31722086803", "type": "NDC" } ], "standard_charges": [ { "minimum": 32.91, "maximum": 109.77, "gross_charge": 116.78, "discounted_cash": 64.23, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 67.73, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.76, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.42, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 98.91, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.98, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 56.05, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 69.95, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 69.83, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 109.77, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 102.77, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.91, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 99.26, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.59, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.14, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 79.41, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 109.77, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 91.44, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.76, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 92.84, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.59, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 102.77, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 67.73, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.76, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TOLVAPTAN 30 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "31722086903", "type": "NDC" } ], "standard_charges": [ { "minimum": 107.19, "maximum": 357.57, "gross_charge": 380.39, "discounted_cash": 209.21, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 220.63, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 207.69, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 304.31, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 322.19, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 110.69, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 182.59, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 227.85, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 227.47, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 357.57, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 334.74, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 107.19, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 323.33, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 285.29, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 134.01, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 258.67, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 357.57, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 297.85, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 207.69, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 302.41, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 285.29, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 334.74, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 220.63, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 207.69, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Tongue and neck surgery", "code_information": [ { "code": "41135", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 28757.94, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 52181.73, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 52181.73, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Tongue base vol reduction", "code_information": [ { "code": "41530", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2390.47, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1770.72, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 7362.91, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 13360.13, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2390.47, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 13360.13, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Tongue mouth jaw surgery", "code_information": [ { "code": "41150", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 16426.74, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 29806.59, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 29806.59, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TOPIRAMATE 100 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68084034401", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TOPIRAMATE 15 MG PO CPSP", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68382000414", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TOPIRAMATE 25 MG PO CPSP", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "2315589506", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TOPIRAMATE 25 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68084034201", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TOPIRAMATE 50 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68084034301", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TOPIRAMATE 6MG/ML ORAL SUSPENSION", "drug_information": { "unit": "33.400000", "type": "UN" }, "code_information": [ { "code": "P6838214100", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TOPIRAMATE ER 100 MG PO CS24", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00832107430", "type": "NDC" } ], "standard_charges": [ { "minimum": 7.76, "maximum": 25.89, "gross_charge": 27.54, "discounted_cash": 15.15, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.97, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.04, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.03, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.33, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.22, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.5, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.47, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.89, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.24, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.76, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.41, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.66, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.7, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.73, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.89, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.56, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.04, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.89, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.66, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.24, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.97, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.04, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TOPOTECAN HCL 4 MG IV SOLR", "drug_information": { "unit": "4.000000", "type": "UN" }, "code_information": [ { "code": "16729015131", "type": "NDC" } ], "standard_charges": [ { "minimum": 125.06, "maximum": 417.17, "gross_charge": 443.8, "discounted_cash": 244.09, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 257.4, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 242.31, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 355.04, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 375.9, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 129.15, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 213.02, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 265.84, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 265.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 417.17, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 390.54, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 125.06, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 377.23, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 332.85, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 156.35, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 301.78, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 417.17, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 347.5, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 242.31, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 352.82, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 332.85, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 390.54, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 257.4, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 242.31, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TORIPALIMAB-TPZI 240 MG/6ML IV SOLN", "drug_information": { "unit": "6.000000", "type": "UN" }, "code_information": [ { "code": "70114034001", "type": "NDC" } ], "standard_charges": [ { "minimum": 21.22, "maximum": 25577.03, "gross_charge": 27209.61, "discounted_cash": 14965.29, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 15781.57, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.22, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21767.69, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23046.54, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7918.0, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13060.61, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 16298.56, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 11394.0, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 25577.03, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23944.46, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 7667.67, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23128.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20407.21, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 9585.95, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 18502.53, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 25577.03, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21305.12, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.65, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 15189.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20407.21, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23944.46, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 15781.57, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.22, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "TORSEMIDE 10 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "50268075515", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TORSEMIDE 100 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "50268075715", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TORSEMIDE 20 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68084053901", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TORSEMIDE 5 MG PO TABS", "drug_information": { "unit": "2.000000", "type": "UN" }, "code_information": [ { "code": "50268075415", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Tot disc arthrp 1ntrspc crv", "code_information": [ { "code": "22856", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 13555.31, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 10040.97, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 36272.21, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 65816.53, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 13555.31, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 65816.53, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Total hip arthroplasty", "code_information": [ { "code": "27130", "type": "HCPCS" }, { "code": "27132", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 9484.13, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 7025.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 36819.94, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 66810.38, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 9484.13, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 66810.38, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Total hysterectomy", "code_information": [ { "code": "58150", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 23071.7, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 41863.98, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 41863.98, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Total knee arthroplasty", "code_information": [ { "code": "27447", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 9484.13, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 7025.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 35942.4, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 65218.12, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 9484.13, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 65218.12, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Tprnl plmt biodegrdabl matrl", "code_information": [ { "code": "55874", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 3747.14, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2775.66, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 30087.27, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 54593.87, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3747.14, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 54593.87, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TRABECTEDIN 1 MG IV SOLR", "drug_information": { "unit": "20.000000", "type": "UN" }, "code_information": [ { "code": "59676061001", "type": "NDC" } ], "standard_charges": [ { "minimum": 198.1, "maximum": 9723.3, "gross_charge": 10343.94, "discounted_cash": 5689.17, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5999.49, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 198.1, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8275.15, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8761.32, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3010.09, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4965.09, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6196.02, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 6185.68, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9723.3, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9102.67, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2914.92, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8792.35, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7757.96, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3644.17, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7033.88, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 9723.3, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8099.31, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 267.43, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 8223.43, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7757.96, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9102.67, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5999.49, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 198.1, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "Trabeculoplasty laser surg", "code_information": [ { "code": "65855", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 404.37, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 299.54, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 1123.92, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 2039.38, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 404.37, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 2039.38, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TRACE MINERALS CU-MN-SE-ZN 300-55-60-3000 MCG/ML IV SOLN", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00517930525", "type": "NDC" } ], "standard_charges": [ { "minimum": 14.8, "maximum": 1158.0, "gross_charge": 52.53, "discounted_cash": 28.89, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.47, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.68, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.6, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.29, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.21, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.47, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.41, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.38, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.23, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.8, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 44.65, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.4, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.51, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.38, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.68, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.76, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.4, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.23, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.47, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.68, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TRAMADOL HCL 50 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687079501", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.25, "maximum": 7.52, "gross_charge": 8.0, "discounted_cash": 4.4, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.4, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.78, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.33, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.84, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.79, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.25, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.8, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.82, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.44, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.26, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.36, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TRAMETINIB DIMETHYL SULFOXIDE 0.5 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00078110515", "type": "NDC" } ], "standard_charges": [ { "minimum": 152.78, "maximum": 509.62, "gross_charge": 542.15, "discounted_cash": 298.18, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 314.45, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 296.01, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 433.72, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 459.2, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 157.77, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 260.23, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 324.75, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 324.21, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 509.62, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 477.09, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 152.78, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 460.83, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 406.61, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 191.0, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 368.66, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 509.62, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 424.5, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 296.01, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 431.01, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 406.61, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 477.09, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 314.45, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 296.01, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TRANDOLAPRIL 4 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68180056801", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TRANEXAMIC ACID 100 MG/ML FOR INHALATION", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "55150018810_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TRANEXAMIC ACID 100 MG/ML TOPICAL SOLN", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "55150018810_3", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TRANEXAMIC ACID 1000 MG/100 ML DRIP RTU", "drug_information": { "unit": "100.000000", "type": "UN" }, "code_information": [ { "code": "51754010803", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 1158.0, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 95.48, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TRANEXAMIC ACID 1000 MG/100 ML INFUSION RTU", "drug_information": { "unit": "100.000000", "type": "UN" }, "code_information": [ { "code": "51754010803_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 1158.0, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 95.48, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TRANEXAMIC ACID 1000 MG/10ML IV SOLN", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "55150018810", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 1158.0, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.72, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TRANEXAMIC ACID 650 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "50268077213", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.82, "maximum": 6.06, "gross_charge": 6.45, "discounted_cash": 3.55, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.74, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.16, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.46, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.88, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.1, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.86, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.86, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.06, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.68, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.82, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.48, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.84, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.27, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.39, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.06, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.05, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.13, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.84, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.68, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.74, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TRANEXAMIC ACID-NACL 1000-0.7 MG/100ML-% IV SOLN", "drug_information": { "unit": "100.000000", "type": "UN" }, "code_information": [ { "code": "51754010803_3", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 1158.0, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 95.48, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Transcath closure of asd", "code_information": [ { "code": "93580", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 13235.9, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 9804.37, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 36140.41, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 65577.39, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 13235.9, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 65577.39, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Transcath closure of vsd", "code_information": [ { "code": "93581", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 13235.9, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 9804.37, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 21918.48, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 39771.42, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 13235.9, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 39771.42, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Transcath occlusion cns", "code_information": [ { "code": "61624", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 56749.62, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 102987.49, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 102987.49, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Transcath occlusion non-cns", "code_information": [ { "code": "61626", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 8359.13, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 6191.95, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 24175.42, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 43866.7, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8359.13, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 43866.7, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Transcath stent cca w/eps", "code_information": [ { "code": "37215", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 41011.86, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 74416.75, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 74416.75, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Transcatheter biopsy", "code_information": [ { "code": "37200", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 3984.54, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2951.51, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 22155.79, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 40202.07, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3984.54, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 40202.07, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Transfer skin pedicle flap", "code_information": [ { "code": "15650", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1348.33, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 998.76, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 14712.53, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 26696.12, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1348.33, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 26696.12, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Transorl lwr esophgl myotomy", "code_information": [ { "code": "43497", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4387.82, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3250.23, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 13417.48, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 24415.08, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4387.82, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 24415.08, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Transperi needle place pros", "code_information": [ { "code": "55875", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 3747.14, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2775.66, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 31408.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 56990.34, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3747.14, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 56990.34, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Transplant forearm tendon", "code_information": [ { "code": "25310", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2391.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1771.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 12028.48, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 21825.87, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2391.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 21825.87, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Transplant hand tendon", "code_information": [ { "code": "26480", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2391.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1771.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 8349.27, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 15149.9, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2391.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 15149.9, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Transplant of thigh tendon", "code_information": [ { "code": "27396", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 5265.64, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3900.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 20666.09, 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"standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3159.31, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2980.49, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3497.1, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2304.91, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "TRASTUZUMAB-ANNS 150 MG IV SOLR", "drug_information": { "unit": "7.150000", "type": "UN" }, "code_information": [ { "code": "55513014101", "type": "NDC" } ], "standard_charges": [ { "minimum": 13.28, "maximum": 3645.95, "gross_charge": 3878.67, "discounted_cash": 2133.27, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2249.63, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3102.94, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3285.23, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1128.69, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1861.76, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2323.32, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2319.44, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3645.95, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3413.23, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1093.01, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3296.87, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2909.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1366.46, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2637.5, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3645.95, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3037.0, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.93, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3083.54, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2909.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3413.23, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", 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Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5929.66, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8688.14, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9198.57, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3160.31, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5212.89, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6505.25, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 6494.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10208.57, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9556.96, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3060.4, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9231.15, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8145.14, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3826.04, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7384.92, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 10208.57, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8503.52, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5929.66, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 8633.84, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8145.14, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9556.96, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6298.9, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5929.66, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TRASTUZUMAB-DKST 150 MG IV SOLR", "drug_information": { "unit": "7.150000", "type": "UN" }, "code_information": [ { "code": "83257000111", "type": "NDC" } ], "standard_charges": [ { "minimum": 29.57, "maximum": 3147.53, "gross_charge": 3348.44, "discounted_cash": 1841.64, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1942.1, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.57, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2678.75, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2836.13, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", 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"Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2946.63, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 943.59, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2846.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2511.33, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1179.66, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2276.94, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3147.53, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2621.83, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.92, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2662.01, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2511.33, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2946.63, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1942.1, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.57, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "TRASTUZUMAB-QYYP 420 MG IV SOLR", "drug_information": { "unit": "20.000000", "type": "UN" }, "code_information": [ { "code": "00069030501", "type": "NDC" } ], "standard_charges": [ { "minimum": 10.47, "maximum": 6864.22, "gross_charge": 7302.36, "discounted_cash": 4016.3, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4235.37, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.47, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5841.89, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6185.1, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2124.99, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3505.13, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4374.11, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4366.81, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6864.22, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6426.08, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2057.81, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6207.01, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5476.77, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2572.62, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4965.6, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6864.22, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5717.75, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.13, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5805.38, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5476.77, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6426.08, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4235.37, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.47, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "TRAVASOL 10 % IV SOLN", "drug_information": { "unit": "2000.000000", "type": "UN" }, "code_information": [ { "code": "00338064406", "type": "NDC" } ], "standard_charges": [ { "minimum": 14.71, "maximum": 1158.0, "gross_charge": 52.2, "discounted_cash": 28.71, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.28, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.5, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.31, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.19, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.06, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.27, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.22, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.07, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.94, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.71, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 44.37, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.15, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.39, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.5, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.07, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.87, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.5, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.5, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.15, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.94, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.28, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.5, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TRAVOPROST (BAK FREE) 0.004 % OP SOLN", "drug_information": { "unit": "2.500000", "type": "UN" }, "code_information": [ { "code": "00378965132", "type": "NDC" } ], "standard_charges": [ { "minimum": 54.53, "maximum": 181.89, "gross_charge": 193.5, "discounted_cash": 106.43, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 112.23, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 105.65, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 154.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 163.89, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 56.31, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 92.88, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 115.91, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 115.71, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 181.89, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 170.28, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.53, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 164.48, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 145.13, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 68.17, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 131.58, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 181.89, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 151.51, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 105.65, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 153.83, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 145.13, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 170.28, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 112.23, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 105.65, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TRAVOPROST 75 MCG IO IMPL", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "25357010001", "type": "NDC" } ], "standard_charges": [ { "minimum": 11394.0, "maximum": 39339.0, "gross_charge": 41850.0, "discounted_cash": 23017.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 24273.0, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 22850.1, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33480.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35446.95, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12178.35, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20088.0, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 25068.15, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 11394.0, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39339.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 36828.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11793.33, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35572.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 31387.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14743.76, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 28458.0, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 39339.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 32768.55, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 22850.1, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 15189.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 31387.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 36828.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24273.0, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 22850.1, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TRAZODONE HCL 100 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687045401", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TRAZODONE HCL 25 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "0182125900", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TRAZODONE HCL 50 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00904686861", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Treat ankle fracture", "code_information": [ { "code": "28445", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 5265.64, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3900.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 8878.41, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 16110.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5265.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 16110.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Treat big toe fracture", "code_information": [ { "code": "28505", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2391.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1771.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 14432.16, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 26187.41, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2391.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 26187.41, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Treat elbow fracture", "code_information": [ { "code": "24586", "type": "HCPCS" }, { "code": "24635", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 9484.13, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 7025.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3900.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 48157.96, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 87383.43, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 9484.13, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5265.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 87383.43, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Treat eyelid by injection", "code_information": [ { "code": "68200", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 294.13, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 217.88, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 3951.65, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 7170.35, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 294.13, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 7170.35, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Treat finger dislocation", "code_information": [ { "code": "26785", "type": "HCPCS" }, { "code": "26775", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2391.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1771.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 1589.18, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 2883.6, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 195.76, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2391.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 2883.6, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Treat finger fracture each", "code_information": [ { "code": "26727", "type": "HCPCS" }, { "code": "26735", "type": "HCPCS" }, { "code": "26740", "type": "HCPCS" }, { "code": "26742", "type": "HCPCS" }, { "code": "26746", "type": "HCPCS" }, { "code": "26765", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2391.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1771.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 130.97, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 873.82, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 5952.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 10800.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2391.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 176.82, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1179.66, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 10800.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Treat foot dislocation", "code_information": [ { "code": "28606", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2391.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1771.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 9232.27, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 16759.3, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2391.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 16759.3, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Treat fracture of radius", "code_information": [ { "code": "25515", "type": "HCPCS" }, { "code": "25525", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 5265.64, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3900.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 16903.96, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 30672.5, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5265.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 30672.5, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Treat fracture of ulna", "code_information": [ { "code": "25545", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 5265.64, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3900.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 17135.71, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 31093.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5265.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 31093.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Treat fracture radius & ulna", "code_information": [ { "code": "25565", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1179.66, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 873.82, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 18135.54, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 32907.26, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1179.66, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 32907.26, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Treat fracture radius/ulna", "code_information": [ { "code": "25575", "type": "HCPCS" }, { "code": "25600", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 5265.64, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3900.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 130.97, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 22188.45, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 40261.28, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5265.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 176.82, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 40261.28, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Treat fracture ulnar styloid", "code_information": [ { "code": "25652", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 5265.64, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3900.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 21337.85, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 38717.93, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5265.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 38717.93, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Treat fx distal radial", "code_information": [ { "code": "25606", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2391.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1771.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 20160.08, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 36580.78, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2391.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 36580.78, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Treat fx rad extra-articul", "code_information": [ { "code": "25607", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 5265.64, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3900.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 16532.17, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 29997.92, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5265.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 29997.92, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Treat fx rad intra-articul", "code_information": [ { "code": "25608", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 5265.64, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3900.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 14023.8, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 25465.01, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5265.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 25465.01, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Treat fx radial 3+ frag", "code_information": [ { "code": "25609", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 5265.64, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3900.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 15897.42, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 28846.12, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5265.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 28846.12, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Treat heel fracture", "code_information": [ { "code": "28415", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 5265.64, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3900.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 25141.79, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 45620.17, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5265.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 45620.17, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Treat humerus fracture", "code_information": [ { "code": "24515", "type": "HCPCS" }, { "code": "24516", "type": "HCPCS" }, { "code": "24538", "type": "HCPCS" }, { "code": "24545", "type": "HCPCS" }, { "code": "24546", "type": "HCPCS" }, { "code": "24566", "type": "HCPCS" }, { "code": "24575", "type": "HCPCS" }, { "code": "24579", "type": "HCPCS" }, { "code": "24582", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 9484.13, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 7025.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3900.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 873.82, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 21791.27, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 39540.61, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 9484.13, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5265.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1179.66, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 39540.61, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Treat knee fracture", "code_information": [ { "code": "27535", "type": "HCPCS" }, { "code": "27536", "type": "HCPCS" }, { "code": "27540", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 22795.33, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 41362.52, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 41362.52, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Treat kneecap dislocation", "code_information": [ { "code": "27566", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 5265.64, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3900.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 21905.7, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 39748.35, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5265.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 39748.35, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Treat kneecap fracture", "code_information": [ { "code": "27524", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 5265.64, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3900.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 19799.78, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 35927.04, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5265.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 35927.04, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Treat lower jaw fracture", "code_information": [ { "code": "21453", "type": "HCPCS" }, { "code": "21461", "type": "HCPCS" }, { "code": "21462", "type": "HCPCS" }, { "code": "21465", "type": "HCPCS" }, { "code": "21470", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4360.43, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3229.95, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 16885.72, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 30639.4, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4360.43, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 30639.4, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Treat lower leg fracture", "code_information": [ { "code": "27826", "type": "HCPCS" }, { "code": "27827", "type": "HCPCS" }, { "code": "27828", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 9484.13, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3900.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 7025.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 11346.08, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 20587.64, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5265.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 9484.13, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 20587.64, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Treat lower leg joint", "code_information": [ { "code": "27829", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 5265.64, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3900.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 18141.25, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 32924.78, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5265.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 32924.78, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Treat metacarpal fracture", "code_information": [ { "code": "26608", "type": "HCPCS" }, { "code": "26615", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2391.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1771.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 5217.55, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 9467.35, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2391.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 9467.35, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Treat metatarsal fracture", "code_information": [ { "code": "28476", "type": "HCPCS" }, { "code": "28485", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 5265.64, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1771.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3900.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 8848.64, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 16070.61, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2391.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5265.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 16070.61, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Treat midfoot fracture each", "code_information": [ { "code": "28465", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 5265.64, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3900.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 15744.7, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 28584.55, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5265.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 28584.55, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Treat mouth roof fracture", "code_information": [ { "code": "21422", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4360.43, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3229.95, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 15510.64, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 28144.3, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4360.43, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 28144.3, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Treat odontoid fx w/o graft", "code_information": [ { "code": "22318", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 28945.27, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 52601.85, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 52601.85, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Treat penis lesion graft", "code_information": [ { "code": "54111", "type": "HCPCS" }, { "code": "54112", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 6816.07, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2775.66, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5048.94, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 17381.29, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 31538.64, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3747.14, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6816.07, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 31538.64, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Treat pleurodesis w/agent", "code_information": [ { "code": "32560", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 455.72, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 337.57, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 3528.74, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 6402.96, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 455.72, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 6402.96, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Treat radius fracture", "code_information": [ { "code": "24655", "type": "HCPCS" }, { "code": "24665", "type": "HCPCS" }, { "code": "24666", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 9484.13, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 873.82, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3900.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 7025.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 21596.18, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 39208.22, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1179.66, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5265.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 9484.13, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 39208.22, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Treat slipped epiphysis", "code_information": [ { "code": "27176", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 11645.18, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 21130.39, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 21130.39, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Treat spinal canal lesion", "code_information": [ { "code": "62282", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 656.23, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 486.1, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 7539.81, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 13681.1, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 656.23, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 13681.1, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Treat thigh fracture", "code_information": [ { "code": "27235", "type": "HCPCS" }, { "code": "27238", "type": "HCPCS" }, { "code": "27248", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 5265.64, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3900.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 873.82, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 20879.66, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 37886.54, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5265.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1179.66, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 37886.54, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Treat thumb fracture", "code_information": [ { "code": "26650", "type": "HCPCS" }, { "code": "26665", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2391.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1771.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 5979.28, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 10849.5, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2391.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 10849.5, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Treat toe dislocation", "code_information": [ { "code": "28665", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 195.76, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 145.01, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 30404.65, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 55333.34, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 195.76, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 55333.34, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Treat toe fracture", "code_information": [ { "code": "28525", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2391.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1771.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 4979.84, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 9039.6, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2391.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 9039.6, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Treat ulnar fracture", "code_information": [ { "code": "24685", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 5265.64, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3900.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 16274.63, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 29530.58, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5265.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 29530.58, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Treat wrist bone fracture", "code_information": [ { "code": "25628", "type": "HCPCS" }, { "code": "25645", "type": "HCPCS" }, { "code": "25650", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 5265.64, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3900.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1771.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 130.97, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 10508.21, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 19067.32, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5265.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2391.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 176.82, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 19067.32, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Treat wrist dislocation", "code_information": [ { "code": "25670", "type": "HCPCS" }, { "code": "25695", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 5265.64, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3900.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 22146.05, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 40328.39, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5265.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 40328.39, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Treatment mouth roof lesion", "code_information": [ { "code": "42160", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2390.47, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1770.72, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 10248.7, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 18596.44, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2390.47, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 18596.44, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Treatment of ankle fracture", "code_information": [ { "code": "27792", "type": "HCPCS" }, { "code": "27814", "type": "HCPCS" }, { "code": "27822", "type": "HCPCS" }, { "code": "27823", "type": "HCPCS" }, { "code": "28436", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 5265.64, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3900.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 16259.43, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 29506.57, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5265.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 29506.57, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Treatment of bone cyst", "code_information": [ { "code": "20615", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 518.62, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 384.16, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 80816.1, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 146642.13, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 518.62, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 146642.13, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Treatment of corneal lesion", "code_information": [ { "code": "65450", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 220.34, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 163.22, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 1215.68, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 2205.89, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 220.34, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 2205.89, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Treatment of fibula fracture", "code_information": [ { "code": "27784", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 5265.64, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3900.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 35269.62, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 64361.8, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5265.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 64361.8, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Treatment of foot infection", "code_information": [ { "code": "28002", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1179.66, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 873.82, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 7411.23, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 13447.8, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1179.66, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 13447.8, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Treatment of gum lesion", "code_information": [ { "code": "41850", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1091.85, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 808.78, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 9077.28, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 16491.23, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1091.85, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 16491.23, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Treatment of miscarriage", "code_information": [ { "code": "59812", "type": "HCPCS" }, { "code": "59821", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2343.63, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1736.02, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 6885.51, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 12493.86, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2343.63, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 12493.86, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Treatment of mouth lesion", "code_information": [ { "code": "40820", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2390.47, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1770.72, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 8610.95, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 15624.72, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2390.47, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 15624.72, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Treatment of penis lesion", "code_information": [ { "code": "54110", "type": "HCPCS" }, { "code": "54115", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2542.24, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1883.14, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1562.68, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 11819.3, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 21446.3, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2542.24, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2109.62, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 21446.3, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Treatment of retinal lesion", "code_information": [ { "code": "67208", "type": "HCPCS" }, { "code": "67210", "type": "HCPCS" }, { "code": "67218", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2779.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 163.22, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 299.54, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2058.97, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 6839.79, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 12410.89, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 220.34, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 404.37, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2779.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 12410.89, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Treatment of thigh fracture", "code_information": [ { "code": "27506", "type": "HCPCS" }, { "code": "27514", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 24285.4, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 44066.24, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 44066.24, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Treatment of tibia fracture", "code_information": [ { "code": "27756", "type": "HCPCS" }, { "code": "27758", "type": "HCPCS" }, { "code": "27759", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 9484.13, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3900.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 7025.28, "standard_charge_percentage": 100.0, "methodology": "fee 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"standard_charge_percentage": 75.0, "estimated_amount": 47109.73, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Treatment of urethra lesion", "code_information": [ { "code": "53220", "type": "HCPCS" }, { "code": "53260", "type": "HCPCS" }, { "code": "53265", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2542.24, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1883.14, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1118.49, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 16385.33, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 32491.98, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2542.24, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1509.96, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 32491.98, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Treatment x10sv retinopathy", "code_information": [ { "code": "67228", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 404.37, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 299.54, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 5158.4, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 9411.63, "methodology": "percent of total billed 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"NDC" } ], "standard_charges": [ { "minimum": 73.96, "maximum": 112179.6, "gross_charge": 119340.0, "discounted_cash": 65637.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 69217.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 73.96, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 95472.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 101080.98, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34727.94, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 57283.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 71484.66, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 11394.0, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 112179.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 105019.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 33630.01, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 101439.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 89505.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 42043.48, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 81151.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 112179.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 93443.22, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 99.84, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 15189.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 89505.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 105019.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 69217.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 73.96, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "TREPROSTINIL 0.6 MG/ML IN SOLN", "drug_information": { "unit": "2.900000", "type": "UN" }, "code_information": [ { "code": "66302020603", "type": "NDC" } ], "standard_charges": [ { "minimum": 962.77, "maximum": 3211.51, "gross_charge": 3416.5, "discounted_cash": 1879.08, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1981.57, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1865.41, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2733.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2893.78, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 994.2, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1639.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2046.48, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2043.07, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3211.51, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3006.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 962.77, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2904.03, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2562.38, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1203.63, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2323.22, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3211.51, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2675.12, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1865.41, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2716.12, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2562.38, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3006.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1981.57, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1865.41, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TREPROSTINIL 1 MG/ML SC SYRINGE CADD MS-3", "drug_information": { "unit": "3.000000", "type": "UN" }, "code_information": [ { "code": "08252000223", "type": "NDC" } ], "standard_charges": [ { "minimum": 62.17, "maximum": 207.39, "gross_charge": 220.63, "discounted_cash": 121.35, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 127.97, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 120.46, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 176.5, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 186.87, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 64.2, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 105.9, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 132.16, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 131.94, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 207.39, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 194.15, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 62.17, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 187.54, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 165.47, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 77.73, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 150.03, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 207.39, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 172.75, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 120.46, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 175.4, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 165.47, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 194.15, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 127.97, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 120.46, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TREPROSTINIL 1 MG/ML SC SYRINGE CADD MS-3 (NICU)", "drug_information": { "unit": "3.000000", "type": "UN" }, "code_information": [ { "code": "08252000298", "type": "NDC" } ], "standard_charges": [ { "minimum": 57.94, "maximum": 193.27, "gross_charge": 205.61, "discounted_cash": 113.09, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 119.25, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 112.26, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 164.49, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 174.15, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.83, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 98.69, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 123.16, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 122.95, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 193.27, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 180.94, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 57.94, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 174.77, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 154.21, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 72.44, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 139.81, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 193.27, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 160.99, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 112.26, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 163.46, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 154.21, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 180.94, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 119.25, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 112.26, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TREPROSTINIL 1 MG/ML SC SYRINGE REMUNITY", "drug_information": { "unit": "3.000000", "type": "UN" }, "code_information": [ { "code": "08252000229", "type": "NDC" } ], "standard_charges": [ { "minimum": 62.17, "maximum": 207.39, "gross_charge": 220.63, "discounted_cash": 121.35, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 127.97, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 120.46, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 176.5, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 186.87, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 64.2, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 105.9, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 132.16, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 131.94, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 207.39, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 194.15, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 62.17, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 187.54, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 165.47, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 77.73, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 150.03, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 207.39, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 172.75, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 120.46, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 175.4, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 165.47, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 194.15, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 127.97, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 120.46, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TREPROSTINIL 10 MG/ML SC SYRINGE CADD MS-3", "drug_information": { "unit": "3.000000", "type": "UN" }, "code_information": [ { "code": "08252000226", "type": "NDC" } ], "standard_charges": [ { "minimum": 613.99, "maximum": 2048.07, "gross_charge": 2178.8, "discounted_cash": 1198.34, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1263.7, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1189.62, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1743.04, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1845.44, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 634.03, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1045.82, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1305.1, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 1302.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2048.07, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1917.34, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 613.99, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1851.98, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1634.1, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 767.59, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1481.58, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2048.07, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1706.0, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1189.62, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1732.15, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1634.1, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1917.34, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1263.7, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1189.62, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TREPROSTINIL 10 MG/ML SC SYRINGE REMUNITY", "drug_information": { "unit": "3.000000", "type": "UN" }, "code_information": [ { "code": "08252000232", "type": "NDC" } ], "standard_charges": [ { "minimum": 613.99, "maximum": 2048.07, "gross_charge": 2178.8, "discounted_cash": 1198.34, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1263.7, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1189.62, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1743.04, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1845.44, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 634.03, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1045.82, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1305.1, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 1302.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2048.07, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": 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"standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1481.58, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2048.07, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1706.0, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1189.62, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1732.15, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1634.1, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1917.34, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1263.7, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1189.62, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TREPROSTINIL 100 MG/20ML IJ SOLN", "drug_information": { "unit": "20.000000", "type": "UN" }, "code_information": [ { "code": "00703068601", "type": "NDC" } ], "standard_charges": [ { "minimum": 30.48, "maximum": 5503.4, "gross_charge": 5854.68, "discounted_cash": 3220.07, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3395.71, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4683.74, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4958.91, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1703.71, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2810.25, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3506.95, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 3501.1, 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"plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4391.01, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2062.6, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3981.18, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5503.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4584.21, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.14, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4654.47, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4391.01, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5152.12, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3395.71, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "TREPROSTINIL 2.5 MG/ML SC SYRINGE CADD MS-3", "drug_information": { "unit": "3.000000", "type": "UN" }, "code_information": [ { "code": "08252000224", "type": "NDC" } ], "standard_charges": [ { "minimum": 147.07, "maximum": 490.58, "gross_charge": 521.89, "discounted_cash": 287.04, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 302.7, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 284.95, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 417.51, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 442.04, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 151.87, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 250.51, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 312.61, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 312.09, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 490.58, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 459.26, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 147.07, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 443.61, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 391.42, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 183.86, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 354.89, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 490.58, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 408.64, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 284.95, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 414.9, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 391.42, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 459.26, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 302.7, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 284.95, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TREPROSTINIL 2.5 MG/ML SC SYRINGE CADD MS-3 (NICU)", "drug_information": { "unit": "3.000000", "type": "UN" }, "code_information": [ { "code": "08252000299", "type": "NDC" } ], "standard_charges": [ { "minimum": 147.07, "maximum": 490.58, "gross_charge": 521.89, "discounted_cash": 287.04, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 302.7, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 284.95, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 417.51, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 442.04, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 151.87, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 250.51, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 312.61, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 312.09, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 490.58, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 459.26, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 147.07, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 443.61, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 391.42, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 183.86, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 354.89, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 490.58, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 408.64, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 284.95, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 414.9, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 391.42, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 459.26, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 302.7, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 284.95, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TREPROSTINIL 2.5 MG/ML SC SYRINGE REMUNITY", "drug_information": { "unit": "3.000000", "type": "UN" }, "code_information": [ { "code": "08252000230", "type": "NDC" } ], "standard_charges": [ { "minimum": 94.14, "maximum": 314.03, "gross_charge": 334.07, "discounted_cash": 183.74, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 193.76, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 182.4, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 267.26, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 282.96, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 97.21, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 160.35, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 200.11, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 199.77, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 314.03, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 293.98, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 94.14, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 283.96, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 250.55, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 117.69, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 227.17, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 314.03, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 261.58, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 182.4, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 265.59, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 250.55, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 293.98, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 193.76, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 182.4, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TREPROSTINIL 20 MG/20ML IJ SOLN", "drug_information": { "unit": "20.000000", "type": "UN" }, "code_information": [ { "code": "42023020601", "type": "NDC" } ], "standard_charges": [ { "minimum": 30.48, "maximum": 3089.56, "gross_charge": 3286.77, "discounted_cash": 1807.72, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1906.33, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2629.42, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2783.89, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 956.45, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1577.65, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1968.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 1965.49, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3089.56, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2892.36, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 926.21, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2793.75, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2465.08, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1157.93, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2235.0, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3089.56, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2573.54, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.14, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2612.98, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2465.08, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2892.36, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1906.33, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "TREPROSTINIL 200 MG/20ML IJ SOLN", "drug_information": { "unit": "20.000000", "type": "UN" }, "code_information": [ { "code": "00703069601", "type": "NDC" } ], "standard_charges": [ { "minimum": 30.48, "maximum": 11006.88, "gross_charge": 11709.45, "discounted_cash": 6440.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 6791.48, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9367.56, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9917.9, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3407.45, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5620.54, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7013.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 7002.25, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11006.88, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10304.32, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3299.72, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9953.03, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8782.09, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 4125.24, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7962.43, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 11006.88, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 9168.5, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.14, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 9309.01, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8782.09, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10304.32, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6791.48, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "TREPROSTINIL 5 MG/ML SC SYRINGE CADD MS-3", "drug_information": { "unit": "3.000000", "type": "UN" }, "code_information": [ { "code": "08252000225", "type": "NDC" } ], "standard_charges": [ { "minimum": 316.86, "maximum": 1056.94, "gross_charge": 1124.4, "discounted_cash": 618.42, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 652.15, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 613.92, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 899.52, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 952.37, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 327.2, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 539.71, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 673.52, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 672.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1056.94, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 989.47, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 316.86, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 955.74, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 843.3, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 396.13, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 764.59, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1056.94, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 880.41, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 613.92, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 893.9, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 843.3, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 989.47, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 652.15, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 613.92, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TREPROSTINIL 5 MG/ML SC SYRINGE REMUNITY", "drug_information": { "unit": "3.000000", "type": "UN" }, "code_information": [ { "code": "08252000231", "type": "NDC" } ], "standard_charges": [ { "minimum": 267.2, "maximum": 891.31, "gross_charge": 948.2, "discounted_cash": 521.51, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 549.96, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 517.72, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 758.56, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 803.13, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 275.93, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 455.14, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 567.97, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 567.02, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 891.31, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 834.42, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 267.2, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 805.97, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 711.15, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 334.05, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 644.78, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 891.31, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 742.44, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 517.72, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 753.82, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 711.15, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 834.42, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 549.96, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 517.72, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TREPROSTINIL 50 MG/20ML IJ SOLN", "drug_information": { "unit": "20.000000", "type": "UN" }, "code_information": [ { "code": "00703067601", "type": "NDC" } ], "standard_charges": [ { "minimum": 30.48, "maximum": 3668.97, "gross_charge": 3903.16, "discounted_cash": 2146.74, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2263.83, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3122.53, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3305.98, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1135.82, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1873.52, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2337.99, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2334.09, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3668.97, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3434.78, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1099.91, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3317.69, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2927.37, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1375.08, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2654.15, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue 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}, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3434.78, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2263.83, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "TREPROSTINIL DIOLAMINE ER 0.125 MG PO TBCR", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "66302030001", "type": "NDC" } ], "standard_charges": [ { "minimum": 5.72, "maximum": 19.09, "gross_charge": 20.31, "discounted_cash": 11.17, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.78, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.09, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.25, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.2, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.91, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.75, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.17, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.15, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.09, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.87, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.72, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.26, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.23, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.16, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.81, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.09, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.9, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.09, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.15, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.23, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.87, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.78, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.09, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TREPROSTINIL DIOLAMINE ER 0.25 MG PO TBCR", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "66302030210", "type": "NDC" } ], "standard_charges": [ { "minimum": 9.98, "maximum": 33.29, "gross_charge": 35.42, "discounted_cash": 19.48, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.54, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.34, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.34, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.31, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.0, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.22, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.18, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.29, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.17, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.98, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.11, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.57, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.48, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.09, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.29, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.73, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.34, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.16, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.57, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.17, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.54, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.34, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TREPROSTINIL DIOLAMINE ER 1 MG PO TBCR", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "66302031002", "type": "NDC" } ], "standard_charges": [ { "minimum": 54.95, "maximum": 183.29, "gross_charge": 194.99, "discounted_cash": 107.24, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 113.09, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 106.46, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 155.99, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 165.16, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 56.74, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 116.8, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 116.6, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 183.29, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 171.59, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.95, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 165.74, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 146.24, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 68.69, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 132.59, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 183.29, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 152.68, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 106.46, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 155.02, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 146.24, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 171.59, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 113.09, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 106.46, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TREPROSTINIL DIOLAMINE ER 2.5 MG PO TBCR", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "66302032502", "type": "NDC" } ], "standard_charges": [ { "minimum": 160.26, "maximum": 534.59, "gross_charge": 568.71, "discounted_cash": 312.79, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 329.85, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 310.52, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 454.97, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 481.7, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 165.49, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 272.98, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 340.66, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 340.09, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 534.59, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 500.46, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 160.26, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 483.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 426.53, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 200.36, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 386.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 534.59, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 445.3, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 310.52, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 452.12, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 426.53, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 500.46, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 329.85, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 310.52, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TREPROSTINIL DIOLAMINE ER 5 MG PO TBCR", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "66302035001", "type": "NDC" } ], "standard_charges": [ { "minimum": 366.31, "maximum": 1221.91, "gross_charge": 1299.9, "discounted_cash": 714.95, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 753.94, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 709.75, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1039.92, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1101.02, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 378.27, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 623.95, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 778.64, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 777.34, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1221.91, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1143.91, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 366.31, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1104.92, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 974.93, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 457.95, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 883.93, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1221.91, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1017.82, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 709.75, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1033.42, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 974.93, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1143.91, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 753.94, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 709.75, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TREPROSTINIL SYRINGE 120000 NG/ML (NICU RX USE)", "drug_information": { "unit": "20.000000", "type": "UN" }, "code_information": [ { "code": "08252000173", "type": "NDC" } ], "standard_charges": [ { "minimum": 452.72, "maximum": 1510.13, "gross_charge": 1606.52, "discounted_cash": 883.59, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 931.78, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 877.16, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1285.22, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1360.72, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 467.5, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 771.13, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 962.31, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 960.7, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1510.13, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1413.74, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 452.72, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1365.54, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1204.89, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 565.98, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1092.43, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1510.13, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1257.91, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 877.16, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1277.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1204.89, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1413.74, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 931.78, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 877.16, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TREPROSTINIL SYRINGE 15000 NG/ML(NICU RX USE)", "drug_information": { "unit": "20.000000", "type": "UN" }, "code_information": [ { "code": "99888000004", "type": "NDC" } ], "standard_charges": [ { "minimum": 452.72, "maximum": 1510.13, "gross_charge": 1606.52, "discounted_cash": 883.59, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 931.78, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 877.16, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1285.22, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1360.72, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 467.5, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 771.13, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 962.31, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 960.7, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1510.13, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1413.74, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 452.72, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1365.54, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1204.89, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 565.98, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1092.43, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1510.13, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1257.91, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 877.16, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1277.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1204.89, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1413.74, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 931.78, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 877.16, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TREPROSTINIL SYRINGE 25000 NG/ML (NICU RX USE)", "drug_information": { "unit": "20.000000", "type": "UN" }, "code_information": [ { "code": 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"additional_payer_notes": "N/A", "standard_charge_dollar": 877.16, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TREPROSTINIL SYRINGE 250000 NG/ML (NICU RX USE)", "drug_information": { "unit": "20.000000", "type": "UN" }, "code_information": [ { "code": "99888000011", "type": "NDC" } ], "standard_charges": [ { "minimum": 452.72, "maximum": 1510.13, "gross_charge": 1606.52, "discounted_cash": 883.59, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 931.78, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 877.16, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { 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billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1257.91, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 877.16, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1277.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1204.89, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1413.74, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 931.78, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 877.16, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TREPROSTINIL SYRINGE 30000 NG/ML (NICU RX USE)", "drug_information": { "unit": "20.000000", "type": "UN" }, "code_information": [ { "code": "08252000172", "type": "NDC" } ], "standard_charges": [ { "minimum": 452.72, "maximum": 1510.13, "gross_charge": 1606.52, "discounted_cash": 883.59, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 931.78, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 877.16, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1285.22, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1360.72, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 467.5, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 771.13, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 962.31, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 960.7, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1510.13, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1413.74, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 452.72, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1365.54, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1204.89, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 565.98, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1092.43, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1510.13, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1257.91, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 877.16, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1277.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1204.89, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1413.74, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 931.78, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 877.16, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TREPROSTINIL SYRINGE 5000 NG/ML(NICU RX USE)", "drug_information": { "unit": "20.000000", "type": "UN" }, "code_information": [ { "code": "99888000003", "type": "NDC" } ], "standard_charges": [ { "minimum": 452.72, "maximum": 1510.13, "gross_charge": 1606.52, "discounted_cash": 883.59, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 931.78, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 877.16, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1285.22, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1360.72, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 467.5, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 771.13, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 962.31, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 960.7, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1510.13, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1413.74, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 452.72, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1365.54, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1204.89, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 565.98, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1092.43, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1510.13, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1257.91, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 877.16, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1277.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1204.89, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1413.74, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 931.78, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 877.16, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TREPROSTINIL SYRINGE 60000 NG/ML (NICU RX USE)", "drug_information": { "unit": "20.000000", "type": "UN" }, "code_information": [ { "code": "99888000005", "type": "NDC" } ], "standard_charges": [ { "minimum": 452.72, "maximum": 1510.13, "gross_charge": 1606.52, "discounted_cash": 883.59, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 931.78, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 877.16, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1285.22, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1360.72, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 467.5, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 771.13, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 962.31, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 960.7, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1510.13, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1413.74, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 452.72, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1365.54, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1204.89, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 565.98, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1092.43, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1510.13, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1257.91, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 877.16, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1277.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1204.89, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1413.74, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 931.78, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 877.16, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TRETINOIN 0.01 % EX GEL", "drug_information": { "unit": "45.000000", "type": "GR" }, "code_information": [ { "code": "00187517245", "type": "NDC" } ], "standard_charges": [ { "minimum": 28.72, "maximum": 95.79, "gross_charge": 101.9, "discounted_cash": 56.05, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.1, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.64, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 81.52, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.31, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.65, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 48.91, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.04, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.94, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 95.79, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 89.67, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.72, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.62, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 76.43, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.9, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 69.29, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 95.79, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 79.79, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.64, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 81.01, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 76.43, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 89.67, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.1, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.64, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TRETINOIN 0.025 % EX GEL", "drug_information": { "unit": "15.000000", "type": "GR" }, "code_information": [ { "code": "00187517015", "type": "NDC" } ], "standard_charges": [ { "minimum": 9.58, "maximum": 31.94, "gross_charge": 33.98, "discounted_cash": 18.69, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.71, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.55, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.78, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.89, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.31, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.35, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.32, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.94, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.9, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.58, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.49, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.97, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.11, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.94, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.61, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.55, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.01, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.49, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.9, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.71, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.55, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TRETINOIN 0.05 % EX CREA", "drug_information": { "unit": "20.000000", "type": "GR" }, "code_information": [ { "code": "51672139400", "type": "NDC" } ], "standard_charges": [ { "minimum": 27.02, "maximum": 90.15, "gross_charge": 95.9, "discounted_cash": 52.75, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.62, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.36, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 76.72, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 81.23, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.91, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.03, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 57.44, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 57.35, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 90.15, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 84.39, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.02, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 81.52, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 71.93, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.79, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.21, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 90.15, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.09, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.36, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 76.24, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 71.93, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 84.39, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.62, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.36, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TRETINOIN 0.05 % EX GEL", "drug_information": { "unit": "45.000000", "type": "GR" }, "code_information": [ { "code": "13548007045", "type": "NDC" } ], "standard_charges": [ { "minimum": 358.86, "maximum": 1197.04, "gross_charge": 1273.45, "discounted_cash": 700.4, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 738.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 695.3, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1018.76, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1078.61, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 370.57, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 611.26, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 762.8, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 761.52, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1197.04, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1120.64, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 358.86, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1082.43, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 955.09, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 448.64, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 865.95, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1197.04, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 997.11, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 695.3, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1012.39, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 955.09, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1120.64, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 738.6, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 695.3, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TRETINOIN 0.1 % EX CREA", "drug_information": { "unit": "20.000000", "type": "GR" }, "code_information": [ { "code": "00574220120", "type": "NDC" } ], "standard_charges": [ { "minimum": 14.45, "maximum": 48.2, "gross_charge": 51.28, "discounted_cash": 28.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.74, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.0, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.02, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.43, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.92, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.61, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.72, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.67, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 48.2, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.13, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.45, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.59, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.46, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.07, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.87, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 48.2, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.15, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.0, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.77, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.46, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.13, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.74, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.0, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TRETINOIN 10 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68084007521", "type": "NDC" } ], "standard_charges": [ { "minimum": 14.26, "maximum": 47.56, "gross_charge": 50.6, "discounted_cash": 27.83, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.35, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.63, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.48, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.86, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.72, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.29, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.31, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.26, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.56, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 44.53, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.26, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.01, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.95, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.83, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.41, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.56, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.62, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.63, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.23, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.95, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 44.53, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.35, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.63, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TRETINOIN 10 MG PO CAPS (DISSOLVED)", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68084007521_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 14.26, "maximum": 47.56, "gross_charge": 50.6, "discounted_cash": 27.83, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.35, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.63, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.48, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.86, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.72, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.29, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.31, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.26, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.56, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 44.53, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.26, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.01, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.95, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.83, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.41, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.56, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.62, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.63, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.23, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.95, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 44.53, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.35, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.63, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TRETINOIN 10 MG/ML ORAL SUSPENSION", "drug_information": { "unit": "100.000000", "type": "UN" }, "code_information": [ { "code": "P8252000164", "type": "NDC" } ], "standard_charges": [ { "minimum": 12.61, "maximum": 42.07, "gross_charge": 44.75, "discounted_cash": 24.61, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.96, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.43, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.9, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.02, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.48, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.81, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.76, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.07, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.38, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.61, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.04, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.56, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.77, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.43, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.07, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.04, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.43, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.58, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.56, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.38, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.96, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.43, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TRIAMCINOLONE (SUPRACHOROIDAL) 40 MG/ML IO SUSP", "drug_information": { "unit": "0.100000", "type": "UN" }, "code_information": [ { "code": "24208004040", "type": "NDC" } ], "standard_charges": [ { "minimum": 26.43, "maximum": 4653.0, "gross_charge": 4950.0, "discounted_cash": 2722.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2871.0, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.43, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3960.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4192.65, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1440.45, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2376.0, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2965.05, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2960.1, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4653.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4356.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1394.91, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4207.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3712.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1743.89, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3366.0, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4653.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3875.85, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.68, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3935.25, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3712.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4356.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2871.0, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.43, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "TRIAMCINOLONE ACET 0.1 % CR 15 G TUBE (BULK CHARGE)", "drug_information": { "unit": "15.000000", "type": "GR" }, "code_information": [ { "code": "45802006435", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TRIAMCINOLONE ACETONIDE 0.025 % EX CREA", "drug_information": { "unit": "15.000000", "type": "GR" }, "code_information": [ { "code": "67877031715", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.21, "maximum": 7.36, "gross_charge": 7.83, "discounted_cash": 4.31, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.54, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.28, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.26, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.63, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.28, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.69, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.68, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.36, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.89, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.21, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.66, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.87, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.76, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.32, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.36, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.28, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.22, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.87, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.89, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.54, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.28, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TRIAMCINOLONE ACETONIDE 0.025 % EX LOTN", "drug_information": { "unit": "60.000000", "type": "UN" }, "code_information": [ { "code": "70752012905", "type": "NDC" } ], "standard_charges": [ { "minimum": 12.41, "maximum": 41.39, "gross_charge": 44.03, "discounted_cash": 24.22, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.54, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.04, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.22, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.29, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.81, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.13, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.37, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.33, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.39, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.41, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.43, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.02, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.51, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.94, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.39, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.48, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.04, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.02, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.54, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.04, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TRIAMCINOLONE ACETONIDE 0.025 % EX OINT", "drug_information": { "unit": "15.000000", "type": "GR" }, "code_information": [ { "code": "45802005435", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.99, "maximum": 6.63, "gross_charge": 7.05, "discounted_cash": 3.88, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.09, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.85, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.64, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.97, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.05, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.38, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.22, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.22, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.63, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.99, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.99, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.29, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.48, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.79, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.63, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.52, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.85, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.6, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.29, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.09, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.85, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TRIAMCINOLONE ACETONIDE 0.1 % EX CREA", "drug_information": { "unit": "15.000000", "type": "GR" }, "code_information": [ { "code": "33342032915", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.97, "maximum": 6.58, "gross_charge": 7.0, "discounted_cash": 3.85, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.06, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.82, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.6, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.93, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.04, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.36, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.19, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.19, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.58, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.16, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.97, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.95, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.25, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.47, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.76, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.58, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.48, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.82, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.57, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.25, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.16, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.06, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.82, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TRIAMCINOLONE ACETONIDE 0.1 % EX LOTN", "drug_information": { "unit": "60.000000", "type": "UN" }, "code_information": [ { "code": "42571038519", "type": "NDC" } ], "standard_charges": [ { "minimum": 10.42, "maximum": 34.76, "gross_charge": 36.98, "discounted_cash": 20.34, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.45, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.19, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.58, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.76, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.75, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.15, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.11, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.54, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.42, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.43, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.74, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.03, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.15, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.96, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.19, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.4, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.74, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.54, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.45, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.19, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TRIAMCINOLONE ACETONIDE 0.1 % EX OINT", "drug_information": { "unit": "30.000000", "type": "GR" }, "code_information": [ { "code": "51672128402", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.74, "maximum": 9.15, "gross_charge": 9.73, "discounted_cash": 5.35, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.31, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.78, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.24, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.83, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.67, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.83, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.82, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.15, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.56, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.74, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.27, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.3, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.43, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.62, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.15, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.62, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.31, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.74, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.3, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.56, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.31, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TRIAMCINOLONE ACETONIDE 0.1 % MT PSTE", "drug_information": { "unit": "5.000000", "type": "GR" }, "code_information": [ { "code": "64980032005", "type": "NDC" } ], "standard_charges": [ { "minimum": 9.05, "maximum": 30.17, "gross_charge": 32.1, "discounted_cash": 17.66, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.62, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.53, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.68, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.19, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.34, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.41, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.23, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.17, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.25, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.05, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.29, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.08, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.31, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.83, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.17, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.53, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.52, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.08, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.25, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.62, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.53, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TRIAMCINOLONE ACETONIDE 0.5 % EX CREA", "drug_information": { "unit": "15.000000", "type": "GR" }, "code_information": [ { "code": "00168000215", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.65, "maximum": 8.84, "gross_charge": 9.4, "discounted_cash": 5.17, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.45, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.13, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.96, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.74, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.51, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.63, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.62, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.84, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.27, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.65, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.99, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.05, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.31, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.39, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.84, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.36, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.13, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.47, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.05, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.27, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.45, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.13, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TRIAMCINOLONE ACETONIDE 0.5 % EX OINT", "drug_information": { "unit": "15.000000", "type": "GR" }, "code_information": [ { "code": "45802004935", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.58, "maximum": 8.6, "gross_charge": 9.15, "discounted_cash": 5.03, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.31, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.0, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.32, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.75, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.66, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.39, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.48, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.47, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.05, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.58, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.78, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.86, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.22, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.22, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.16, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.0, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.27, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.86, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.05, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.31, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.0, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TRIAMCINOLONE ACETONIDE 10 MG/ML IJ SUSP", "drug_information": { "unit": "0.250000", "type": "UN" }, "code_information": [ { "code": "00003049420", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TRIAMCINOLONE ACETONIDE 40 MG/ML IJ SUSP", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "67457062205", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TRIAMCINOLONE ACETONIDE 40 MG/ML IJ SUSP 1ML VIAL (BULK CHARGE)", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00703024101", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TRIAMCINOLONE ACETONIDE 40 MG/ML IO SUSP", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00078089778", "type": "NDC" } ], "standard_charges": [ { "minimum": 963.74, "maximum": 3214.76, "gross_charge": 3419.96, "discounted_cash": 1880.98, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1983.58, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1867.3, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2735.97, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2896.71, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 995.21, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1641.58, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2048.56, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2045.14, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3214.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3009.56, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 963.74, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2906.97, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2564.97, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1204.85, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2325.57, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3214.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2677.83, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1867.3, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2718.87, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2564.97, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3009.56, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1983.58, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1867.3, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TRIAMCINOLONE ACETONIDE 55 MCG/ACT NA AERO", "drug_information": { "unit": "17.000000", "type": "UN" }, "code_information": [ { "code": "46122038576", "type": "NDC" } ], "standard_charges": [ { "minimum": 15.01, "maximum": 50.06, "gross_charge": 53.25, "discounted_cash": 29.29, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.89, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.07, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.6, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.1, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.5, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.56, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.9, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.84, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.06, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.86, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.01, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.26, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.94, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.76, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.21, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.06, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.69, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.07, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.33, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.94, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.86, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.89, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.07, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TRIAMCINOLONE ACETONIDE 80 MG/ML IJ SUSP", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00003031505", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.95, "maximum": 39.86, "gross_charge": 42.4, "discounted_cash": 23.32, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.59, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.15, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.92, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.91, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.34, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.35, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.36, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.86, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.31, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.95, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.04, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.94, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.83, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.86, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.2, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.15, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.71, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.31, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.59, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.15, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TRIAMTERENE-HCTZ 37.5-25 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68084075025", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TRICHLOROACETIC ACID 45 % EX SOLN", "drug_information": { "unit": "30.000000", "type": "UN" }, "code_information": [ { "code": "P494527915145", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 1158.0, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.47, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TRICHLOROACETIC ACID 50 % EX SOLN", "drug_information": { "unit": "30.000000", "type": "UN" }, "code_information": [ { "code": "P8252000058", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.2, "maximum": 1158.0, "gross_charge": 4.25, "discounted_cash": 2.34, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.47, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.69, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.24, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.04, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.55, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.54, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.74, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.2, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.61, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.19, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.5, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.89, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.33, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.38, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.19, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.74, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.47, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TRIFLUOPERAZINE HCL 1 MG PO TABS", "drug_information": { "unit": "2.000000", "type": "UN" }, "code_information": [ { "code": "51079057220", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.16, "maximum": 3.87, "gross_charge": 4.12, "discounted_cash": 2.27, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.25, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.3, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.49, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.2, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.98, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.47, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.46, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.87, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.63, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.09, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.45, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.87, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.23, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.25, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.28, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.09, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.63, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.25, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TRIFLUOPERAZINE HCL 10 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "51079057520", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.39, "maximum": 4.62, "gross_charge": 4.92, "discounted_cash": 2.71, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.85, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.69, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.94, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.43, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.36, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.95, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.94, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.62, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.33, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.39, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.18, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.69, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.73, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.35, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.62, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.85, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.69, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.91, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.69, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.33, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.85, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.69, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TRIFLUOPERAZINE HCL 2 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "51079057320", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TRIFLUOPERAZINE HCL 5 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "51079057420", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TRIFLURIDINE 1 % OP SOLN", "drug_information": { "unit": "7.500000", "type": "UN" }, "code_information": [ { "code": "61314004475", "type": "NDC" } ], "standard_charges": [ { "minimum": 150.5, "maximum": 502.03, "gross_charge": 534.07, "discounted_cash": 293.74, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 309.76, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 291.6, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 427.26, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 452.36, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 155.41, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 256.35, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 319.91, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 319.37, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 502.03, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 469.98, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 150.5, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 453.96, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 400.55, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 188.15, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 363.17, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 502.03, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 418.18, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 291.6, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 424.59, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 400.55, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 469.98, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 309.76, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 291.6, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TRIHEXYPHENIDYL HCL 0.4 MG/ML PO SOLN", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "00121065816", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TRIHEXYPHENIDYL HCL 2 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00591533501", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TRIMETHOBENZAMIDE HCL 100 MG/ML IM SOLN", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "42023011925", "type": "NDC" } ], "standard_charges": [ { "minimum": 15.46, "maximum": 51.56, "gross_charge": 54.85, "discounted_cash": 30.17, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.81, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.95, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.88, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.46, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.96, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.33, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.86, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.8, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 51.56, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 48.27, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.46, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.62, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.14, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.32, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.3, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 51.56, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.95, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.95, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.61, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.14, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 48.27, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.81, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.95, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TRIMETHOBENZAMIDE HCL 300 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "4338666003", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.46, "maximum": 38.23, "gross_charge": 40.67, "discounted_cash": 22.37, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.59, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.21, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.54, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.45, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.83, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.52, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.36, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.32, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.23, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.79, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.46, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.57, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.33, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.66, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.23, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.84, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.21, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.33, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.79, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.59, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.21, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TRINATAL RX 1 60-1 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "13811000710", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TRIPLE ANTIBIOTIC 3.5-400-5000 MG-UNIT EX OINT", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "45802014301", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.56, "maximum": 8.55, "gross_charge": 9.1, "discounted_cash": 5.01, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.28, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.97, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.28, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.71, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.65, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.45, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.44, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.55, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.01, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.56, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.74, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.83, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.21, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.19, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.55, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.97, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.23, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.83, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.01, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.28, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.97, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TRIPTORELIN PAMOATE ER (CPP) 22.5 MG IM SRER", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "24338015020", "type": "NDC" } ], "standard_charges": [ { "minimum": 1866.5, "maximum": 56007.34, "gross_charge": 59582.28, "discounted_cash": 32770.25, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 34557.72, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1866.5, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 47665.82, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 50466.19, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17338.44, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 28599.49, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 35689.79, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 11394.0, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 56007.34, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52432.41, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 16790.29, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 50644.94, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 44686.71, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 20990.84, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 40515.95, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 56007.34, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 46652.93, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2519.77, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 15189.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 44686.71, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52432.41, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 34557.72, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1866.5, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "Trluml balo angiop 1st art", "code_information": [ { "code": "37246", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4202.59, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3113.03, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 23902.01, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 43370.59, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4202.59, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 43370.59, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Trluml balo angiop 1st vein", "code_information": [ { "code": "37248", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4202.59, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3113.03, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 21173.28, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 38419.29, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4202.59, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 38419.29, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Trluml dil aq o/f can w/o st", "code_information": [ { "code": "66174", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2965.25, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2196.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 6593.39, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 11963.8, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2965.25, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 11963.8, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Trluml dil aq o/f can w/st", "code_information": [ { "code": "66175", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 3803.22, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2817.2, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 8573.09, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 15715.28, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3803.22, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 15715.28, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Trml dstrj ios bvn 1st 2 l/s", "code_information": [ { "code": "64628", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 9484.13, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 7025.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 20505.62, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 37207.77, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 9484.13, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 37207.77, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TROPHAMINE 6.8 % CUSTOM IV SOLN", "drug_information": { "unit": "500.000000", "type": "UN" }, "code_information": [ { "code": "08252000032", "type": "NDC" } ], "standard_charges": [ { "minimum": 1127.2, "maximum": 3760.0, "gross_charge": 4000.0, "discounted_cash": 2200.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2320.0, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2184.0, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3472.0, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1164.0, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1920.0, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2396.0, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2392.0, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3760.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3520.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1127.2, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3400.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3000.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1409.2, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2720.0, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3760.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3132.0, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2184.0, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3180.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3000.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3520.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2320.0, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2184.0, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TROPIC-CYCLOP-PE-KETO-PROPAR OP SOSY", "drug_information": { "unit": "0.500000", "type": "UN" }, "code_information": [ { "code": "71266822101", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TROPICAMIDE 0.5 % OP SOLN", "drug_information": { "unit": "15.000000", "type": "UN" }, "code_information": [ { "code": "24208059064", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TROPICAMIDE 1 % OP SOLN", "drug_information": { "unit": "15.000000", "type": "UN" }, "code_information": [ { "code": "70069012101", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TROPICAMIDE-CYCLOPENTOLATE-PE 1-1-2.5 % OP SOLN", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "71266821101", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TROSPIUM CHLORIDE 20 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68462046160", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TRYPAN BLUE 0.06 % IO SOSY", "drug_information": { "unit": "0.500000", "type": "UN" }, "code_information": [ { "code": "68803061210", "type": "NDC" } ], "standard_charges": [ { "minimum": 43.28, "maximum": 144.38, "gross_charge": 153.6, "discounted_cash": 84.48, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 89.09, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 83.87, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 122.88, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 130.1, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 44.7, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 73.73, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 92.01, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 91.85, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 144.38, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 135.17, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.28, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 130.56, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 115.2, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.11, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 104.45, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 144.38, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 120.27, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 83.87, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 122.11, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 115.2, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 135.17, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 89.09, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 83.87, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Ttvi/rplcmt w/prstc vlv perq", "code_information": [ { "code": "0646T", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 82948.45, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 150511.28, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 150511.28, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TUBERCULIN PPD 5 UNIT/0.1ML ID SOLN", "drug_information": { "unit": "0.100000", "type": "UN" }, "code_information": [ { "code": "49281075221", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 1158.0, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.72, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TUBERCULIN PPD 5 UNIT/0.1ML ID SOLN (NPH USE ONLY)", "drug_information": { "unit": "0.100000", "type": "UN" }, "code_information": [ { "code": "49281075221_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 1158.0, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.72, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Tx supfc wnd dehsn smpl clsr", "code_information": [ { "code": "12020", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 451.2, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 334.22, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 7436.12, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 13512.09, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 451.2, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 13512.09, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TYPHOID VACCINE PO CPDR", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "69401000002", "type": "NDC" } ], "standard_charges": [ { "minimum": 14.85, "maximum": 49.55, "gross_charge": 52.71, "discounted_cash": 28.99, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.57, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.78, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.17, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 44.65, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.34, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.3, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.57, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.52, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.55, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.38, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.85, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 44.8, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.53, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.57, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.84, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.55, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.27, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.78, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.9, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.53, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.38, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.57, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.78, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "TYPHOID VI POLYSACCHARIDE VACC 25 MCG/0.5ML IM SOSY", "drug_information": { "unit": "0.500000", "type": "UN" }, "code_information": [ { "code": "49281079051", "type": "NDC" } ], "standard_charges": [ { "minimum": 124.69, "maximum": 415.92, "gross_charge": 442.47, "discounted_cash": 243.36, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 256.63, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 241.59, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 353.98, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 374.77, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 128.76, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 212.39, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 265.04, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 264.6, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 415.92, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 389.37, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 124.69, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 376.1, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 331.85, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 155.88, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 300.88, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 415.92, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 346.45, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 241.59, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 351.76, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 331.85, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 389.37, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 256.63, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 241.59, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "U/s trtmt, not leiomyomata", "code_information": [ { "code": "C9734", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 25739.4, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 46704.64, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 46704.64, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ULIPRISTAL ACETATE 30 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "73302045601", "type": "NDC" } ], "standard_charges": [ { "minimum": 24.73, "maximum": 82.49, "gross_charge": 87.75, "discounted_cash": 48.26, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.9, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.91, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 70.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.32, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.54, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.12, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.56, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.47, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.49, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 77.22, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.73, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.59, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.81, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.91, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 59.67, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.49, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 68.71, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.91, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 69.76, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.81, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 77.22, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.9, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.91, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "UMECLIDINIUM-VILANTEROL 62.5-25 MCG/ACT IN AEPB", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00173086906", "type": "NDC" } ], "standard_charges": [ { "minimum": 41.42, "maximum": 138.15, "gross_charge": 146.97, "discounted_cash": 80.83, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 85.24, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 80.25, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 117.58, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 124.48, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.77, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 70.55, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.04, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 138.15, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 129.33, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.42, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 124.92, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 110.23, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 51.78, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 99.94, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 138.15, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 115.08, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 80.25, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 116.84, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 110.23, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 129.33, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 85.24, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 80.25, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Unlistd px hemic/lymphtc sys", "code_information": [ { "code": "38999", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 322.25, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 238.7, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 9503.71, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 17244.63, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 322.25, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 17244.63, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Unlistd px skn muc memb subq", "code_information": [ { "code": "17999", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 146.46, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 108.49, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 37085.22, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 67291.72, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 146.46, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 67291.72, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Unlisted cranfcl&maxlfcl px", "code_information": [ { "code": "21299", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 171.17, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 126.79, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 20223.94, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 36991.22, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 171.17, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 36991.22, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Unlisted fetal invas px w/us", "code_information": [ { "code": "59897", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 148.28, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 109.84, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 3908.61, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 7092.24, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 148.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 7092.24, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Unlisted hystsc px uterus", "code_information": [ { "code": "58579", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 148.28, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 109.84, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 15563.92, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 28240.98, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 148.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 28240.98, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Unlisted laps px appendix", "code_information": [ { "code": "44979", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4300.51, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3185.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 32880.54, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 59662.3, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4300.51, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 59662.3, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Unlisted laps px bladder", "code_information": [ { "code": "51999", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4300.51, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3185.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 46731.82, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 84795.66, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4300.51, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 84795.66, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Unlisted laps px esoph", "code_information": [ { "code": "43289", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4300.51, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3185.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 25059.14, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 45470.2, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4300.51, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 45470.2, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Unlisted laps px intestine", "code_information": [ { "code": "44238", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4300.51, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3185.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 23577.35, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 42781.48, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4300.51, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 42781.48, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Unlisted laps px liver", "code_information": [ { "code": "47379", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4300.51, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3185.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 17925.11, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 34148.82, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4300.51, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 34148.82, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Unlisted laps px lymphtc sys", "code_information": [ { "code": "38589", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4300.51, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3185.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 37415.83, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 70897.05, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4300.51, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 70897.05, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Unlisted laps px renal", "code_information": [ { "code": "50549", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4300.51, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3185.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 52154.56, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 94635.3, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4300.51, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 94635.3, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Unlisted laps px spleen", "code_information": [ { "code": "38129", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4300.51, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3185.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 29681.68, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 53857.88, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4300.51, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 53857.88, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Unlisted laps px stomach", "code_information": [ { "code": "43659", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4300.51, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3185.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 17925.11, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 34148.82, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4300.51, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 34148.82, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Unlisted laps px ureter", "code_information": [ { "code": "50949", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4300.51, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3185.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 25545.42, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 48395.42, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4300.51, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 48395.42, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Unlisted laps px uterus", "code_information": [ { "code": "58578", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4300.51, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3185.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 47871.28, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 86863.24, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4300.51, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 86863.24, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Unlisted muscskel px head", "code_information": [ { "code": "21499", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 171.17, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 126.79, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 25914.03, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 47021.4, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 171.17, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 47021.4, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Unlisted procedure anus", "code_information": [ { "code": "46999", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 672.02, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 497.79, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 7912.19, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 14356.8, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 672.02, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 14356.8, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Unlisted procedure breast", "code_information": [ { "code": "19499", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2822.56, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2090.79, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 62443.16, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 114212.61, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2822.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 114212.61, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Unlisted procedure colon", "code_information": [ { "code": "45399", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 672.02, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 497.79, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 3149.6, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 5715.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 672.02, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 5715.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Unlisted procedure esophagus", "code_information": [ { "code": "43499", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 691.08, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 511.91, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 16331.63, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 29634.04, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 691.08, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 29634.04, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Unlisted procedure eyelids", "code_information": [ { "code": "67999", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 220.34, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 163.22, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 7239.34, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 13135.89, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 220.34, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 13135.89, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Unlisted procedure larynx", "code_information": [ { "code": "31599", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 171.17, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 126.79, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 12496.73, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 22675.53, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 171.17, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 22675.53, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Unlisted procedure lips", "code_information": [ { "code": "40799", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 171.17, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 126.79, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 19398.59, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 35199.04, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 171.17, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 35199.04, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Unlisted procedure nose", "code_information": [ { "code": "30999", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 171.17, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 126.79, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 11847.69, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 21497.84, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 171.17, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 21497.84, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Unlisted procedure orbit", "code_information": [ { "code": "67599", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 220.34, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 163.22, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 14320.95, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 26073.15, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 220.34, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 26073.15, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Unlisted procedure pancreas", "code_information": [ { "code": "48999", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 518.62, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 384.16, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 2507.28, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 4549.5, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 518.62, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 4549.5, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Unlisted procedure rectum", "code_information": [ { "code": "45999", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 672.02, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 497.79, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 3981.34, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 7224.22, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 672.02, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 7224.22, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Unlisted procedure shoulder", "code_information": [ { "code": "23929", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 176.82, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 130.97, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 14219.32, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 26020.79, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 176.82, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 26020.79, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Unlisted procedure spine", "code_information": [ { "code": "22899", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 176.82, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 130.97, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 22545.32, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 40908.87, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 176.82, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 40908.87, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Unlisted procedure stomach", "code_information": [ { "code": "43999", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 691.08, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 511.91, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 6437.09, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 11680.24, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 691.08, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 11680.24, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Unlisted px abd pertm&omn", "code_information": [ { "code": "49999", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 691.08, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 511.91, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 14497.4, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 26305.77, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 691.08, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 26305.77, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Unlisted px abdomen muscskel", "code_information": [ { "code": "22999", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 176.82, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 130.97, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 25245.35, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 45808.11, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 176.82, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 45808.11, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Unlisted px accessory sinus", "code_information": [ { "code": "31299", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 171.17, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 126.79, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 23784.63, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 43444.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 171.17, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 43444.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Unlisted px ant segment eye", "code_information": [ { "code": "66999", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1681.13, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1245.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 7697.97, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 14416.58, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1681.13, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 14416.58, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Unlisted px arthroscopy", "code_information": [ { "code": "29999", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 176.82, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 130.97, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 20270.32, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 36780.86, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 176.82, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 36780.86, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Unlisted px biliary tract", "code_information": [ { "code": "47999", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 691.08, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 511.91, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 16119.34, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 29248.81, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 691.08, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 29248.81, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Unlisted px cardiac surgery", "code_information": [ { "code": "33999", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 455.72, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 337.57, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 33297.82, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 60419.45, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 455.72, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 60419.45, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Unlisted px conjunctiva", "code_information": [ { "code": "68399", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 220.34, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 163.22, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 6140.57, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 11142.18, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 220.34, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 11142.18, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Unlisted px dentalvlr strux", "code_information": [ { "code": "41899", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 171.17, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 126.79, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 5599.04, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 10159.54, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 171.17, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 10159.54, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Unlisted px diaphragm", "code_information": [ { "code": "39599", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 43745.26, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 79376.49, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 79376.49, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Unlisted px endocrine system", "code_information": [ { "code": "60699", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4300.51, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 11673.36, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 21181.5, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4300.51, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 21181.5, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Unlisted px external ear", "code_information": [ { "code": "69399", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 171.17, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 126.79, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 29086.57, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 52778.03, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 171.17, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 52778.03, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Unlisted px extraocular musc", "code_information": [ { "code": "67399", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 220.34, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 163.22, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 11013.68, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 19984.52, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 220.34, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 19984.52, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Unlisted px femur/knee", "code_information": [ { "code": "27599", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 176.82, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 130.97, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 19671.27, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 35693.84, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 176.82, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 35693.84, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Unlisted px fml genital sys", "code_information": [ { "code": "58999", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 148.28, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 109.84, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 13574.16, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 24630.53, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 148.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 24630.53, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Unlisted px foot/toes", "code_information": [ { "code": "28899", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 176.82, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 130.97, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 9409.43, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 17073.56, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 176.82, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 17073.56, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Unlisted px forearm/wrist", "code_information": [ { "code": "25999", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 176.82, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 130.97, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 25746.68, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 46717.78, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 176.82, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 46717.78, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Unlisted px hands/fingers", "code_information": [ { "code": "26989", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 176.82, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 130.97, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 11235.77, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 20387.57, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 176.82, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 20387.57, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Unlisted px humerus/elbow", "code_information": [ { "code": "24999", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 176.82, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 130.97, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 12707.26, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 23057.54, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 176.82, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 23057.54, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Unlisted px inner ear", "code_information": [ { "code": "69949", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 171.17, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 126.79, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 12936.35, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 23473.22, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 171.17, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 23473.22, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Unlisted px lacrimal system", "code_information": [ { "code": "68899", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 220.34, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 163.22, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 9323.45, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 16917.55, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 220.34, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 16917.55, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Unlisted px leg/ankle", "code_information": [ { "code": "27899", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 176.82, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 130.97, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 25938.51, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 47065.85, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 176.82, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 47065.85, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Unlisted px lungs & pleura", "code_information": [ { "code": "32999", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 455.72, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 337.57, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 16442.52, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 29835.22, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 455.72, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 29835.22, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Unlisted px male genital sys", "code_information": [ { "code": "55899", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 179.27, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 132.79, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 10665.77, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 19353.22, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 179.27, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 19353.22, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Unlisted px mat care&dlvr", "code_information": [ { "code": "59899", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 148.28, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 109.84, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 6091.45, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 11053.03, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 148.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 11053.03, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Unlisted px middle ear", "code_information": [ { "code": "69799", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 171.17, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 126.79, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 10247.39, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 18601.11, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 171.17, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 18601.11, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Unlisted px muscskel general", "code_information": [ { "code": "20999", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 176.82, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 130.97, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 6978.72, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 12663.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 176.82, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 12663.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Unlisted px neck/thorax", "code_information": [ { "code": "21899", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 171.17, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 126.79, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 15670.03, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 28433.48, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 171.17, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 28433.48, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Unlisted px nervous system", "code_information": [ { "code": "64999", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 217.58, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 161.17, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 4024.27, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 7302.11, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 217.58, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 7302.11, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Unlisted px palate uvula", "code_information": [ { "code": "42299", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 171.17, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 126.79, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 18602.38, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 33754.38, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 171.17, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 33754.38, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Unlisted px pelvis/hip joint", "code_information": [ { "code": "27299", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 176.82, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 130.97, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 14580.15, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 26456.02, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 176.82, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 26456.02, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Unlisted px phrnx adnd/tnsl", "code_information": [ { "code": "42999", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 171.17, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 126.79, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 20352.93, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 36930.74, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 171.17, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 36930.74, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Unlisted px posterior segmnt", "code_information": [ { "code": "67299", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1681.13, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1245.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 1183.28, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 2147.09, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1681.13, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 2147.09, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Unlisted px salivry glnd/dux", "code_information": [ { "code": "42699", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 171.17, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 126.79, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 11145.43, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 20223.56, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 171.17, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 20223.56, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Unlisted px small intestine", "code_information": [ { "code": "44799", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 691.08, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 511.91, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 4677.28, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 8487.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 691.08, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 8487.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Unlisted px tongue flr mouth", "code_information": [ { "code": "41599", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 171.17, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 126.79, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 15883.71, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 28821.31, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 171.17, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 28821.31, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Unlisted px trachea bronchi", "code_information": [ { "code": "31899", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 143.1, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 106.0, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 9691.63, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 17585.63, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 143.1, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 17585.63, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Unlisted px urinary system", "code_information": [ { "code": "53899", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 179.27, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 132.79, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 12006.89, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 21786.72, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 179.27, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 21786.72, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Unlisted px vascular njx", "code_information": [ { "code": "36299", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 0.75, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 35783.34, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 64929.48, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 64929.48, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Unlisted px vascular surgery", "code_information": [ { "code": "37799", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 455.72, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 337.57, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 10627.06, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 19282.98, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 455.72, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 19282.98, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Unlisted px vestibule mouth", "code_information": [ { "code": "40899", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 171.17, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 126.79, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 51143.47, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 92800.7, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 171.17, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 92800.7, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Unlstd laps px abd pertm&omn", "code_information": [ { "code": "49329", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4300.51, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3185.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 27451.55, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 49811.27, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4300.51, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 49811.27, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Unlstd laps px hrnap hrnrphy", "code_information": [ { "code": "49659", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4300.51, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3185.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 17704.72, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 32125.49, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4300.51, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 32125.49, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Unlstd laps px sprmatic cord", "code_information": [ { "code": "55559", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 4300.51, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3185.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 17945.18, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 32831.8, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4300.51, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 32831.8, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "UPADACITINIB ER 30 MG PO TB24", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00074231030", "type": "NDC" } ], "standard_charges": [ { "minimum": 191.5, "maximum": 638.78, "gross_charge": 679.55, "discounted_cash": 373.75, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 394.14, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 371.03, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 543.64, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 575.58, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 197.75, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 326.18, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 407.05, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 406.37, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 638.78, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 598.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 191.5, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 577.62, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 509.66, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 239.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 462.09, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 638.78, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 532.09, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 371.03, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 540.24, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 509.66, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 598.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 394.14, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 371.03, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Upgrade of pacemaker system", "code_information": [ { "code": "33214", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 7713.99, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5714.07, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 37585.56, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 68199.61, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7713.99, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 68199.61, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Uppr gi scope w/submuc inj", "code_information": [ { "code": "43236", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 691.08, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 511.91, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 4276.6, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 7759.96, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 691.08, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 7759.96, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "UREA 15 G PO PACK", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "62530000011", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.81, "maximum": 9.37, "gross_charge": 9.97, "discounted_cash": 5.48, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.78, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.44, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.98, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.44, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.9, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.79, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.97, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.37, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.77, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.81, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.47, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.48, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.51, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.78, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.37, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.81, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.44, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.93, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.48, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.77, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.78, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.44, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "UREA 20 % EX CREA", "drug_information": { "unit": "85.000000", "type": "GR" }, "code_information": [ { "code": "00536110945", "type": "NDC" } ], "standard_charges": [ { "minimum": 4.63, "maximum": 15.44, "gross_charge": 16.43, "discounted_cash": 9.04, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.53, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.97, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.14, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.92, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.78, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.89, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.84, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.83, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.44, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.46, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.63, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.97, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.32, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.79, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.17, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.44, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.86, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.97, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.06, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.32, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.46, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.53, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.97, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "UREA 40 % EX CREA", "drug_information": { "unit": "29.000000", "type": "GR" }, "code_information": [ { "code": "44523061701", "type": "NDC" } ], "standard_charges": [ { "minimum": 37.01, "maximum": 123.47, "gross_charge": 131.35, "discounted_cash": 72.24, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 76.18, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 71.72, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 105.08, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 111.25, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.22, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.05, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 78.68, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 78.55, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 123.47, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 115.59, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.01, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 111.65, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 98.51, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.27, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 89.32, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 123.47, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 102.85, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 71.72, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 104.42, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 98.51, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 115.59, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 76.18, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 71.72, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Ureter endoscopy & treatment", "code_information": [ { "code": "50961", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 3747.14, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2775.66, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 16236.8, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 29461.96, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3747.14, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 29461.96, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Urethrlys transvag w/ scope", "code_information": [ { "code": "53500", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2542.24, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1883.14, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 9580.24, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 17383.5, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2542.24, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 17383.5, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "URSODIOL 250 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687052721", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "URSODIOL 300 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "50268079715", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "URSODIOL 50 MG/ML ORAL SUSPENSION", "drug_information": { "unit": "6.000000", "type": "UN" }, "code_information": [ { "code": "R5155209066", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "URSODIOL 50 MG/ML ORAL SUSPENSION (EP ORAL)", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "P0115152401", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "URSODIOL 500 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68001037800", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Us leiomyomata ablate <200", "code_information": [ { "code": "0071T", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2343.63, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 8099.68, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 14697.01, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2343.63, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 14697.01, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "USTEKINUMAB 130 MG/26ML IV SOLN", "drug_information": { "unit": "52.000000", "type": "UN" }, "code_information": [ { "code": "57894005427", "type": "NDC" } ], "standard_charges": [ { "minimum": 3421.33, "maximum": 11412.54, "gross_charge": 12141.0, "discounted_cash": 6677.55, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 7041.78, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 6628.99, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9712.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10283.43, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3533.03, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5827.68, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7272.46, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 7260.32, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11412.54, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10684.08, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3421.33, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10319.85, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9105.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 4277.27, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 8255.88, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 11412.54, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 9506.4, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6628.99, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 9652.1, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9105.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10684.08, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7041.78, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6628.99, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "USTEKINUMAB 45 MG/0.5ML SC SOSY", "drug_information": { "unit": "0.500000", "type": "UN" }, "code_information": [ { "code": "57894006003", "type": "NDC" } ], "standard_charges": [ { "minimum": 10872.48, "maximum": 36267.32, "gross_charge": 38582.25, "discounted_cash": 21220.24, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 22377.71, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21065.91, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30865.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32679.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11227.43, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 18519.48, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23110.77, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 11394.0, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 36267.32, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33952.38, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 10872.48, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32794.91, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 28936.69, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 13592.53, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 26235.93, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 36267.32, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 30209.9, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21065.91, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 15189.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 28936.69, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33952.38, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 22377.71, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21065.91, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "USTEKINUMAB 90 MG/ML SC SOSY", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "57894006103", "type": "NDC" } ], "standard_charges": [ { "minimum": 11394.0, "maximum": 71112.7, "gross_charge": 75651.81, "discounted_cash": 41608.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 43878.05, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 41305.89, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 60521.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 64077.08, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 22014.68, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 36312.87, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 45315.43, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 11394.0, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 71112.7, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 66573.59, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 21318.68, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 64304.04, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 56738.86, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 26652.13, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 51443.23, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 71112.7, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 59235.37, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 41305.89, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 15189.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 56738.86, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 66573.59, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 43878.05, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 41305.89, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Vag hyst complex", "code_information": [ { "code": "58290", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 5450.71, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4037.57, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 15511.54, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 28145.94, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5450.71, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 28145.94, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Vag hyst incl t/o complex", "code_information": [ { "code": "58291", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 3638.66, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2695.3, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 25344.29, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 47179.23, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3638.66, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 47179.23, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Vag hyst including t/o", "code_information": [ { "code": "58262", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 3638.66, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2695.3, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 24168.84, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 43854.76, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3638.66, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 43854.76, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Vag hyst w/enterocele repair", "code_information": [ { "code": "58270", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 3638.66, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2695.3, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 19536.07, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 35448.53, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3638.66, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 35448.53, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Vaginal hysterectomy", "code_information": [ { "code": "58260", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 3638.66, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2695.3, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 28372.54, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 51482.41, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3638.66, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 51482.41, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "VALACYCLOVIR 50 MG/ML ORAL SUSPENSION", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "P0378427693", "type": "NDC" } ], "standard_charges": [ { "minimum": 4.14, "maximum": 13.8, "gross_charge": 14.68, "discounted_cash": 8.07, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.51, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.02, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.74, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.43, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.27, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.05, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.79, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.92, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.14, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.48, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.01, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.17, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.98, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.49, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.02, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.67, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.01, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.92, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.51, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.02, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "VALACYCLOVIR HCL 1 G PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68084030921", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.22, "maximum": 4.07, "gross_charge": 4.33, "discounted_cash": 2.38, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.51, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.36, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.46, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.67, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.26, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.08, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.59, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.59, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.07, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.81, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.22, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.68, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.25, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.53, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.94, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.07, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.36, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.44, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.25, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.81, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.51, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.36, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "VALACYCLOVIR HCL 500 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68084021501", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "VALGANCICLOVIR HCL 450 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68084096525", "type": "NDC" } ], "standard_charges": [ { "minimum": 5.46, "maximum": 18.21, "gross_charge": 19.37, "discounted_cash": 10.65, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.23, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.58, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.5, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.41, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.3, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.6, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.58, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.21, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.05, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.46, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.46, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.53, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.82, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.17, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.21, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.17, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.58, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.4, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.53, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.05, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.23, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.58, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "VALGANCICLOVIR HCL 50 MG/ML PO SOLR", "drug_information": { "unit": "9.000000", "type": "UN" }, "code_information": [ { "code": "70010005140", "type": "NDC" } ], "standard_charges": [ { "minimum": 20.46, "maximum": 68.23, "gross_charge": 72.59, "discounted_cash": 39.92, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.1, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.63, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 58.07, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.48, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.12, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.84, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.48, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.41, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 68.23, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.88, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.46, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.7, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.44, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.57, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.36, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 68.23, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 56.84, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.63, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 57.71, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.44, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.88, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.1, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.63, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "VALINE 50 MG/ML ORAL SOLUTION", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "P5155239805", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 1158.0, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.47, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "VALPROATE SODIUM 100 MG/ML IV SOLN", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "00143978510", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 1158.0, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.72, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "VALPROIC ACID 250 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "63739008610", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "VALPROIC ACID 250 MG/5ML PO SOLN", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "00121467540", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "VALPROIC ACID 250 MG/5ML PO SOLN (EP ORAL)", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "00121467540_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "VALRUBICIN 40 MG/ML IS SOLN", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "67979000101", "type": "NDC" } ], "standard_charges": [ { "minimum": 784.65, "maximum": 5797.46, "gross_charge": 6167.51, "discounted_cash": 3392.13, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3577.16, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 784.65, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4934.01, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5223.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1794.75, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2960.4, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3694.34, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 3688.17, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5797.46, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5427.41, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1738.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5242.38, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4625.63, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2172.81, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4193.91, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5797.46, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4829.16, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1059.27, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4903.17, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4625.63, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5427.41, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3577.16, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 784.65, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "VALSARTAN 160 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687063401", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "VALSARTAN 320 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00078036034", "type": "NDC" } ], "standard_charges": [ { "minimum": 8.03, "maximum": 26.77, "gross_charge": 28.48, "discounted_cash": 15.66, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.52, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.55, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.78, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.12, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.29, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.67, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.06, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.03, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.77, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.06, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.03, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.21, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.36, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.03, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.37, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.77, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.3, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.55, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.64, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.36, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.06, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.52, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.55, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "VALSARTAN 40 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "R5974636030", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "VALSARTAN 80 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687062301", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "VALSARTAN-HYDROCHLOROTHIAZIDE 160-12.5 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00378632277", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "VALSARTAN-HYDROCHLOROTHIAZIDE 160-25 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00078038334", "type": "NDC" } ], "standard_charges": [ { "minimum": 8.19, "maximum": 27.31, "gross_charge": 29.05, "discounted_cash": 15.98, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.85, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.86, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.24, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.61, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.45, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.94, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.37, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.31, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.56, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.19, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.69, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.79, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.23, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.75, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.31, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.75, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.86, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.09, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.79, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.56, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.85, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.86, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "VALSARTAN-HYDROCHLOROTHIAZIDE 320-12.5 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00378632477", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "VALSARTAN-HYDROCHLOROTHIAZIDE 320-25 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00078047234", "type": "NDC" } ], "standard_charges": [ { "minimum": 10.37, "maximum": 34.6, "gross_charge": 36.81, "discounted_cash": 20.25, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.35, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.1, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.18, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.71, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.67, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.05, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.01, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.39, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.37, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.29, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.61, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.97, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.03, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.82, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.1, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.26, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.61, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.39, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.35, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.1, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "VALSARTAN-HYDROCHLOROTHIAZIDE 80-12.5 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00378632177", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "VANCOMYCIN 1 GM/200 ML RTU", "drug_information": { "unit": "200.000000", "type": "UN" }, "code_information": [ { "code": "00338355248", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "VANCOMYCIN 1 GM/250 ML D5W RTU IVAS", "drug_information": { "unit": "250.000000", "type": "UN" }, "code_information": [ { "code": "08252000166", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "VANCOMYCIN 1 GM/250 ML NS RTU IVAS", "drug_information": { "unit": "250.000000", "type": "UN" }, "code_information": [ { "code": "08252012345", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "VANCOMYCIN 1 MG/ML IRRIGATION SOLN", "drug_information": { "unit": "500.000000", "type": "UN" }, "code_information": [ { "code": "08252433201", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "VANCOMYCIN 1.25 GM/250 ML RTU", "drug_information": { "unit": "250.000000", "type": "UN" }, "code_information": [ { "code": "00338012204", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "VANCOMYCIN 1.5 GM/300 ML RTU", "drug_information": { "unit": "300.000000", "type": "UN" }, "code_information": [ { "code": "00338012404", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "VANCOMYCIN 5 MG/ML IVPB-RTU (PEDS)", "drug_information": { "unit": "150.000000", "type": "UN" }, "code_information": [ { "code": "00338358048", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "VANCOMYCIN 5 MG/ML SYR-RTU (NICU)", "drug_information": { "unit": "150.000000", "type": "UN" }, "code_information": [ { "code": "00338358048_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "VANCOMYCIN 5 MG/ML SYR-RTU (PEDS)", "drug_information": { "unit": "150.000000", "type": "UN" }, "code_information": [ { "code": "00338358048_3", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "VANCOMYCIN 500 MG/100 ML RTU", "drug_information": { "unit": "100.000000", "type": "UN" }, "code_information": [ { "code": "00338355148", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "VANCOMYCIN 750 MG/150 ML RTU", "drug_information": { "unit": "150.000000", "type": "UN" }, "code_information": [ { "code": "00338358048_4", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "VANCOMYCIN CONTINUOUS INFUSION 1 G/200 ML RTU", "drug_information": { "unit": "200.000000", "type": "UN" }, "code_information": [ { "code": "00338355248_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "VANCOMYCIN CONTINUOUS INFUSION 1 G/250 ML NS RTU IVAS", "drug_information": { "unit": "250.000000", "type": "UN" }, "code_information": [ { "code": "08252012345_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "VANCOMYCIN CONTINUOUS INFUSION 1 G/250 ML RTU IVAS", "drug_information": { "unit": "250.000000", "type": "UN" }, "code_information": [ { "code": "08252000166_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "VANCOMYCIN CONTINUOUS INFUSION 750 MG/150 ML RTU", "drug_information": { "unit": "150.000000", "type": "UN" }, "code_information": [ { "code": "00338358048_5", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "VANCOMYCIN CONTINUOUS INFUSION INGREDIENT", "drug_information": { "unit": "20.000000", "type": "UN" }, "code_information": [ { "code": "00143916210", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "VANCOMYCIN HCL 1 G IV SOLR", "drug_information": { "unit": "20.000000", "type": "UN" }, "code_information": [ { "code": "00143916210_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "VANCOMYCIN HCL 10 G IV SOLR", "drug_information": { "unit": "100.000000", "type": "UN" }, "code_information": [ { "code": "25021015899", "type": "NDC" } ], "standard_charges": [ { "minimum": 75.8, "maximum": 252.84, "gross_charge": 268.98, "discounted_cash": 147.94, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 156.01, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 146.86, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 215.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 227.83, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 78.27, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 129.11, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 161.12, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 160.85, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 252.84, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 236.7, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 75.8, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 228.63, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 201.74, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 94.76, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 182.91, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 252.84, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 210.61, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 146.86, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 213.84, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 201.74, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 236.7, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 156.01, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 146.86, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "VANCOMYCIN HCL 125 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "42494045020", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "VANCOMYCIN HCL 250 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00121089020", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.55, "maximum": 8.52, "gross_charge": 9.06, "discounted_cash": 4.98, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.25, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.95, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.25, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.67, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.35, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.43, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.42, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.97, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.55, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.7, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.8, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.19, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.16, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.09, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.95, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.8, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.97, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.25, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.95, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "VANCOMYCIN HCL 5 G IV SOLR", "drug_information": { "unit": "100.000000", "type": "UN" }, "code_information": [ { "code": "25021015799", "type": "NDC" } ], "standard_charges": [ { "minimum": 12.6, "maximum": 42.05, "gross_charge": 44.73, "discounted_cash": 24.6, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.94, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.42, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.78, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.89, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.02, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.47, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.79, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.75, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.05, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.36, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.6, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.02, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.55, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.76, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.42, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.05, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.02, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.42, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.56, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.55, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.36, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.94, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.42, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "VANCOMYCIN HCL 50 MG/ML PO SOLR", "drug_information": { "unit": "150.000000", "type": "UN" }, "code_information": [ { "code": "52536010605", "type": "NDC" } ], "standard_charges": [ { "minimum": 81.45, "maximum": 271.69, "gross_charge": 289.03, "discounted_cash": 158.97, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 167.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 157.81, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 231.22, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 244.81, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 84.11, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 138.73, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 173.13, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 172.84, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 271.69, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 254.35, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 81.45, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 245.68, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 216.77, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 101.83, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 196.54, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 271.69, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 226.31, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 157.81, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 229.78, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 216.77, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 254.35, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 167.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 157.81, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "VANCOMYCIN HCL 500 MG IV SOLR", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "00409433201", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "VANCOMYCIN HCL 500 MG TOPICAL", "drug_information": { "unit": "500.000000", "type": "ME" }, "code_information": [ { "code": "00409433201_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "VANCOMYCIN INTRAVITREAL INJ (1MG/0.05ML)", "drug_information": { "unit": "0.050000", "type": "UN" }, "code_information": [ { "code": "C0409433202", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "VANCOMYCIN INTRAVITREAL INJ (1MG/0.1ML)", "drug_information": { "unit": "0.100000", "type": "UN" }, "code_information": [ { "code": "C0409433201", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "VANCOMYCIN OPHTHALMIC SOLN 25 MG/ML", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "0069258703", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "VANCOMYCIN OPHTHALMIC SOLN 50 MG/ML", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "08252002700", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "VANCOMYCIN SUBCONJUNCTIVAL INJ (25 MG/0.5 ML)", "drug_information": { "unit": "0.500000", "type": "UN" }, "code_information": [ { "code": "08252001400", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "VANICREAM EX CREA", "drug_information": { "unit": "113.000000", "type": "GR" }, "code_information": [ { "code": "45334030004", "type": "NDC" } ], "standard_charges": [ { "minimum": 3.44, "maximum": 11.47, "gross_charge": 12.2, "discounted_cash": 6.71, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.08, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.66, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.76, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.33, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.55, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.86, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.31, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.3, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.47, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.74, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.44, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.37, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.15, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.3, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.3, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.47, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.55, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.66, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.7, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.15, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.74, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.08, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.66, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "VARENICLINE TARTRATE 0.5 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "49884015576", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "VARENICLINE TARTRATE 1 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687064821", "type": "NDC" } ], "standard_charges": [ { "minimum": 5.27, "maximum": 17.57, "gross_charge": 18.69, "discounted_cash": 10.28, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.84, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.2, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.95, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.83, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.44, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.97, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.2, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.18, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.57, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.45, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.89, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.02, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.58, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.71, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.57, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.63, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.2, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.86, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.02, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.45, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.84, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.2, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "VARICELLA VIRUS VACCINE LIVE 1350 PFU/0.5ML IJ SUSR", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00006482700", "type": "NDC" } ], "standard_charges": [ { "minimum": 171.51, "maximum": 572.09, "gross_charge": 608.61, "discounted_cash": 334.74, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 352.99, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 332.3, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 486.89, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 515.49, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 177.11, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 292.13, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 364.56, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 363.95, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 572.09, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 535.58, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 171.51, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 517.32, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 456.46, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 214.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 413.85, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 572.09, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 476.54, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 332.3, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 483.84, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 456.46, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 535.58, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 352.99, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 332.3, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "VARICELLA-ZOSTER IMMUNE GLOB 125 UNIT/1.2ML IM SOLN", "drug_information": { "unit": "0.600000", "type": "UN" }, "code_information": [ { "code": "70257012651", "type": "NDC" } ], "standard_charges": [ { "minimum": 1228.89, "maximum": 5948.68, "gross_charge": 6328.38, "discounted_cash": 3480.61, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3670.46, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1228.89, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5062.7, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5360.14, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1841.56, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3037.62, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3790.7, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 3784.37, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5948.68, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5568.97, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1783.34, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5379.12, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4746.29, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2229.49, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4303.3, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5948.68, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4955.12, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1659.0, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5031.06, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4746.29, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5568.97, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3670.46, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1228.89, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "Vasc embolize/occlude artery", "code_information": [ { "code": "37242", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 13235.9, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 9804.37, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 32442.42, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 58867.3, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 13235.9, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 58867.3, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Vasc embolize/occlude bleed", "code_information": [ { "code": "37244", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 8359.13, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 6191.95, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 48292.05, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 87626.76, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8359.13, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 87626.76, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Vasc embolize/occlude organ", "code_information": [ { "code": "37243", "type": "HCPCS" } ], 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billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 48285.14, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8359.13, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 48285.14, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "VASOPRESSIN 10 UNITS/50 ML DRIP SYRINGE - CODE USE", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "55150037025", "type": "NDC" } ], "standard_charges": [ { "minimum": 19.73, "maximum": 65.8, 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"plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.37, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.6, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.93, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.86, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.8, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { 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"additional_generic_notes": "" } ] }, { "description": "VASOPRESSIN 20 UNIT/ML IV SOLN", "drug_information": { "unit": "0.130000", "type": "UN" }, "code_information": [ { "code": "43598091425", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": 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60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": 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"percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "VASOPRESSIN 40 UNITS/100 ML RTU", "drug_information": { "unit": "100.000000", "type": "UN" }, "code_information": [ { "code": "00338964712_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.06, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.06, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.78, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.06, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "VASOPRESSIN 40 UNITS/100 ML RTU|DISCARDED DRUG NOT ADMINISTERED", "drug_information": { "unit": "100.000000", "type": "UN" }, "code_information": [ { "code": "00338964712", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.06, "maximum": 98.85, "gross_charge": 105.16, "discounted_cash": 57.84, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.99, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.06, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 84.13, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 89.07, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.6, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.48, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 62.99, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 62.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 98.85, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 92.54, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.63, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 89.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 78.87, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.05, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 71.51, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 98.85, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.34, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.78, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 83.6, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 78.87, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 92.54, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.99, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.06, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "VASOPRESSIN IN NS 20 UNITS/100 ML RTU (MULTI-GPI)", "drug_information": { "unit": "100.000000", "type": "UN" }, "code_information": [ { "code": "00338964012_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "VASOPRESSIN IN NS 20 UNITS/100 ML RTU (MULTI-GPI)|DISCARDED DRUG NOT ADMINISTERED", "drug_information": { "unit": "100.000000", "type": "UN" }, "code_information": [ { "code": "00338964012", "type": "NDC" } ], "standard_charges": [ { "minimum": 15.15, "maximum": 50.53, "gross_charge": 53.76, "discounted_cash": 29.57, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.18, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.35, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.01, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.53, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.2, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.15, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.53, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.31, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.15, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.7, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.32, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.94, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.56, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.53, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.09, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.35, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.74, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.32, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.31, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.18, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.35, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "VAXCHORA PO SUSR", "drug_information": { "unit": "100.000000", "type": "UN" }, "code_information": [ { "code": "50632001502", "type": "NDC" } ], "standard_charges": [ { "minimum": 151.55, "maximum": 505.51, "gross_charge": 537.78, "discounted_cash": 295.78, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 311.91, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 293.63, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 430.22, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 455.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 156.49, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 258.13, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 322.13, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 321.59, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 505.51, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 473.25, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 151.55, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 457.11, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 403.34, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 189.46, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 365.69, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 505.51, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 421.08, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 293.63, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 427.54, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 403.34, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 473.25, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 311.91, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 293.63, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "VECURONIUM BROMIDE 10 MG IV SOLR", "drug_information": { "unit": "10.000000", "type": "ME" }, "code_information": [ { "code": "55150023510", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 1158.0, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.72, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "VEDOLIZUMAB 300 MG IV SOLR", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "64764030020", "type": "NDC" } ], "standard_charges": [ { "minimum": 7326.73, "maximum": 24439.76, "gross_charge": 25999.74, "discounted_cash": 14299.86, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 15079.85, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 14195.86, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20799.79, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 22021.78, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7565.92, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12479.88, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 15573.84, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 11394.0, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 24439.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 22879.77, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 7326.73, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 22099.78, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19499.81, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 9159.71, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 17679.82, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 24439.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 20357.8, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 14195.86, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 15189.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19499.81, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 22879.77, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 15079.85, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 14195.86, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "VELAGLUCERASE ALFA 400 UNITS IV SOLR", "drug_information": { "unit": "4.000000", "type": "UN" }, "code_information": [ { "code": "54092070104", "type": "NDC" } ], "standard_charges": [ { "minimum": 1235.01, "maximum": 4119.63, "gross_charge": 4382.58, "discounted_cash": 2410.42, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2541.9, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2392.89, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3506.06, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3712.05, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1275.33, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2103.64, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2625.17, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2620.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4119.63, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3856.67, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1235.01, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3725.19, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3286.94, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1543.98, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2980.15, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4119.63, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3431.56, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2392.89, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3484.15, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3286.94, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3856.67, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2541.9, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2392.89, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "VENELEX EX OINT", "drug_information": { "unit": "56.700000", "type": "GR" }, "code_information": [ { "code": "58980078021", "type": "NDC" } ], "standard_charges": [ { "minimum": 12.55, "maximum": 41.88, "gross_charge": 44.55, "discounted_cash": 24.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.84, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.32, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.64, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.73, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.96, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.38, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.69, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 26.64, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.88, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.55, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.87, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.41, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.69, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.29, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.88, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.88, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.32, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.42, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.41, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.84, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.32, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "VENETOCLAX 100 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00074057611", "type": "NDC" } ], "standard_charges": [ { "minimum": 126.72, "maximum": 422.7, "gross_charge": 449.68, "discounted_cash": 247.32, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 260.81, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 245.53, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 359.74, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 380.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 130.86, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 215.85, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 269.36, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 268.91, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 422.7, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 395.72, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 126.72, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 382.23, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 337.26, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 158.42, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 305.78, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 422.7, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 352.1, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 245.53, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 357.5, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 337.26, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 395.72, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 260.81, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 245.53, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "VENLAFAXINE HCL 100 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "1671465901", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "VENLAFAXINE HCL 25 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68084089625", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "VENLAFAXINE HCL 37.5 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68084084401", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "VENLAFAXINE HCL 50 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68382002001", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "VENLAFAXINE HCL 75 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68084085601", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, 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"standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "VENLAFAXINE HCL ER 150 MG PO CP24", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68084071301", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "VENLAFAXINE HCL ER 37.5 MG PO CP24", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68084069801", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "VENLAFAXINE HCL ER 75 MG PO CP24", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68084070901", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Venous mech thrombectomy", "code_information": [ { "code": "37187", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 8359.13, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 6191.95, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 39612.17, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 71876.94, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8359.13, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 71876.94, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "VERAPAMIL 10MG/ML ORAL SUSPENSION", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "P0378077201", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "VERAPAMIL HCL 2.5 MG/ML IV SOLN", "drug_information": { "unit": "2.000000", "type": "UN" }, "code_information": [ { "code": "70710164307", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 1158.0, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.72, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "VERAPAMIL HCL 40 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "R0591040401", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "VERAPAMIL HCL 80 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "2315502601", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "VERAPAMIL HCL ER 100 MG PO CP24", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "62175048537", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.05, "maximum": 6.84, "gross_charge": 7.28, "discounted_cash": 4.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.22, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.97, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.82, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.12, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.49, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.36, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.35, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.84, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.41, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.05, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.19, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.46, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.56, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.95, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.84, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.7, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.97, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.79, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.46, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.41, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.22, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.97, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "VERAPAMIL HCL ER 120 MG PO CP24", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "51079091720", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.18, "maximum": 7.29, "gross_charge": 7.75, "discounted_cash": 4.26, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.5, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.23, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.56, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.26, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.72, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.63, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.29, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.82, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.59, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.81, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.73, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.27, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.29, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.07, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.23, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.16, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.81, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.82, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.5, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.23, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "VERAPAMIL HCL ER 120 MG PO TBCR", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "4335392116", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "VERAPAMIL HCL ER 180 MG PO TBCR", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "R7583415801", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "VERTEPORFIN 15 MG IV SOLR", "drug_information": { "unit": "7.500000", "type": "UN" }, "code_information": [ { "code": "00187560015", "type": "NDC" } ], "standard_charges": [ { "minimum": 6.3, "maximum": 4574.63, "gross_charge": 4866.63, "discounted_cash": 2676.65, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2822.65, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.3, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3893.3, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4122.04, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1416.19, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2335.98, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2915.11, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2910.24, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4574.63, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4282.63, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1371.42, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4136.64, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3649.97, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1714.51, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3309.31, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4574.63, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3810.57, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.5, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3868.97, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3649.97, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4282.63, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2822.65, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.3, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "VIGABATRIN 500 MG PO PACK", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "69097096453", "type": "NDC" } ], "standard_charges": [ { "minimum": 3.83, "maximum": 12.77, "gross_charge": 13.59, "discounted_cash": 7.47, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.88, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.42, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.87, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.51, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.95, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.52, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.14, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.13, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.77, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.96, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.83, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.55, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.19, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.79, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.24, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.77, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.64, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.42, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.19, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.96, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.88, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.42, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "VILAZODONE HCL 10 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00456111030", "type": "NDC" } ], "standard_charges": [ { "minimum": 7.39, "maximum": 24.64, "gross_charge": 26.21, "discounted_cash": 14.42, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.31, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.97, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.2, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.63, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.58, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.7, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.67, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.64, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.06, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.39, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.28, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.66, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.23, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.82, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.64, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.52, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.31, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.84, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.66, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.06, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.31, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "VILAZODONE HCL 20 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "62332023330", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "VILAZODONE HCL 40 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00456114030", "type": "NDC" } ], "standard_charges": [ { "minimum": 7.39, "maximum": 24.64, "gross_charge": 26.21, "discounted_cash": 14.42, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.31, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.97, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.2, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.63, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.58, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.7, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.67, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.64, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.06, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.39, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.28, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.66, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.23, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.82, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.64, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.52, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.31, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.84, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.66, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.06, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.31, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "VINBLASTINE SULFATE 1 MG/ML IV SOLN", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "63323027810", "type": "NDC" } ], "standard_charges": [ { "minimum": 33.96, "maximum": 113.27, "gross_charge": 120.5, "discounted_cash": 66.28, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 69.89, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.79, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.4, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 102.06, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.07, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 57.84, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 72.18, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 72.06, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 113.27, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 106.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.96, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 102.43, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 90.38, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.45, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 81.94, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 113.27, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 94.35, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.79, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 95.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 90.38, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 106.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 69.89, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.79, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "VINCRISTINE SULFATE 1 MG/ML IV SOLN", "drug_information": { "unit": "2.000000", "type": "UN" }, "code_information": [ { "code": "61703030906", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "VINORELBINE TARTRATE 10 MG/ML IV SOLN", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "25021020401", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "VINORELBINE TARTRATE 50 MG/5ML IV SOLN", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "25021020405", "type": "NDC" } ], "standard_charges": [ { "minimum": 21.7, "maximum": 72.38, "gross_charge": 77.0, "discounted_cash": 42.35, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 44.66, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.04, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.6, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.22, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.41, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.96, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.12, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.05, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 72.38, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 67.76, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.7, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.45, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 57.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.13, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.36, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 72.38, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.29, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.04, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 61.22, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 57.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 67.76, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 44.66, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.04, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "VISMODEGIB 150 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "50242014001", "type": "NDC" } ], "standard_charges": [ { "minimum": 538.18, "maximum": 1795.2, "gross_charge": 1909.79, "discounted_cash": 1050.38, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1107.68, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1042.75, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1527.83, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1617.59, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 555.75, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 916.7, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1143.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 1142.05, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1795.2, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1680.62, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 538.18, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1623.32, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1432.34, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 672.82, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1298.66, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1795.2, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1495.37, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1042.75, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1518.28, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1432.34, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1680.62, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1107.68, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1042.75, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "VISTASEAL 10 ML EX KIT", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "61953001401", "type": "NDC" } ], "standard_charges": [ { "minimum": 599.02, "maximum": 1998.16, "gross_charge": 2125.7, "discounted_cash": 1169.14, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1232.91, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1160.63, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1700.56, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1800.47, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 618.58, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1020.34, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1273.29, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 1271.17, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1998.16, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1870.62, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 599.02, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1806.85, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1594.28, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 748.88, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1445.48, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1998.16, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1664.42, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1160.63, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1689.93, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1594.28, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1870.62, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1232.91, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1160.63, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Visualization of windpipe", "code_information": [ { "code": "31615", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 375.37, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 278.05, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 8774.5, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 15921.47, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 375.37, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 15921.47, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Vit for macular hole", "code_information": [ { "code": "67042", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2965.25, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2196.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 9067.68, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 16453.45, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2965.25, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 16453.45, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Vit for macular pucker", "code_information": [ { "code": "67041", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2965.25, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2196.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 8481.55, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 15389.9, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2965.25, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 15389.9, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Vit for membrane dissect", "code_information": [ { "code": "67043", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2965.25, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2196.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 12000.62, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 21775.33, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2965.25, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 21775.33, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "VITAMIN A & D EX OINT (MULTI-GPI)", "drug_information": { "unit": "113.000000", "type": "GR" }, "code_information": [ { "code": "71399012204", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.66, "maximum": 5.53, "gross_charge": 5.88, "discounted_cash": 3.23, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.41, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.21, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.7, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.98, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.71, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.82, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.53, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.17, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.66, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.41, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.07, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.0, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.53, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.6, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.21, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.67, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.41, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.17, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.41, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.21, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "VITAMIN A 15000 MCG (50000 UNITS)/ML IM SOLN", "drug_information": { "unit": "2.000000", "type": "UN" }, "code_information": [ { "code": "70199002611", "type": "NDC" } ], "standard_charges": [ { "minimum": 733.78, "maximum": 2447.68, "gross_charge": 2603.92, "discounted_cash": 1432.16, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1510.27, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1421.74, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2260.2, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 757.74, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1249.88, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1559.75, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 1557.14, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2447.68, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2291.45, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 733.78, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2213.33, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1952.94, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 917.36, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1770.67, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2447.68, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2038.87, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1421.74, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2070.12, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1952.94, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2291.45, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1510.27, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1421.74, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "VITAMIN A 2400 MCG (8000 UT) PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "79854010005", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "VITAMIN A 3000 MCG (10000 UT) PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "R0904208560", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "VITAMIN A 3000 MCG (10000 UT) PO CAPS (FOR PO PEDS)", "drug_information": { "unit": "0.160000", "type": "UN" }, "code_information": [ { "code": "00904208560", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "VITAMIN B-1 50 MG PO TABS", "drug_information": { "unit": "2.000000", "type": "UN" }, "code_information": [ { "code": "80681009700", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "VITAMIN B-12 100 MCG PO TABS", "drug_information": { "unit": "3.000000", "type": "UN" }, "code_information": [ { "code": "50268085215", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "VITAMIN B-12 1000 MCG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "77333093810", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "VITAMIN B-12 250 MCG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "50268085315", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "VITAMIN B-12 500 MCG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "50268085415", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "VITAMIN B-2 100 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "43292056000", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "VITAMIN B-6 100 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "50268085915_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "VITAMIN B-COMPLEX 100 IJ SOLN", "drug_information": { "unit": "30.000000", "type": "UN" }, "code_information": [ { "code": "67457014630", "type": "NDC" } ], "standard_charges": [ { "minimum": 163.33, "maximum": 1158.0, "gross_charge": 579.6, "discounted_cash": 318.78, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 336.17, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 316.46, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 503.09, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 168.66, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 278.21, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 347.18, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 346.6, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 544.82, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 510.05, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 163.33, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 492.66, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 434.7, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 204.19, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 394.13, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 544.82, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 453.83, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 316.46, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 460.78, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 434.7, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 510.05, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 336.17, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 316.46, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "VITAMIN C 250 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "50268086015", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "VITAMIN C 500 MG/5ML PO LIQD (MULTI-GPI)", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "1785616005", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", 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Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": 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"standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "VITAMIN D (CHOLECALCIFEROL) 10 MCG (400 UNIT) PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "77333094810", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "VITAMIN E 180 MG (400 UNIT) PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "77333095110", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "VITAMIN E 45 MG (100 UNIT) PO CAPS", "drug_information": { "unit": "4.000000", "type": "UN" }, "code_information": [ { "code": "80681013400", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "VITAMIN E 450 MG (1000 UNIT) PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00904027746", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "VITAMIN E 6.75 MG (15 UNITS)/0.3ML PO SOLN", "drug_information": { "unit": "30.000000", "type": "UN" }, "code_information": [ { "code": "71321080230", "type": "NDC" } ], "standard_charges": [ { "minimum": 15.06, "maximum": 50.22, "gross_charge": 53.43, "discounted_cash": 29.39, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.99, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.17, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.74, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.26, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.55, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.65, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.95, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.22, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.02, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.06, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.42, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.07, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.82, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.33, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 50.22, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 41.84, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.17, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 42.48, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.07, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.02, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.99, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.17, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "VITAMIN K1 1 MG/0.5ML IJ SOLN", "drug_information": { "unit": "0.500000", "type": "UN" }, "code_information": [ { "code": "00409915701_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "VITAMIN K1 10 MG/ML IJ SOLN", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00409915801", "type": "NDC" } ], "standard_charges": [ { "minimum": 16.34, "maximum": 54.51, "gross_charge": 57.99, "discounted_cash": 31.89, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.63, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.66, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.39, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.12, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.88, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.84, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.74, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.68, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.51, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 51.03, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.34, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.29, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.49, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.43, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.43, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 54.51, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 45.41, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.66, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 46.1, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.49, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 51.03, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.63, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.66, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "VITAMINS MULTIPLE SYRINGE (PED)", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "54643564601", "type": "NDC" }, { "code": "54643564700", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 1158.0, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.72, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Volume deplete of harvest", "code_information": [ { "code": "38214", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 322.25, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 8055.25, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 14616.39, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 322.25, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 14616.39, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "VON WILLEBRAND FACTOR (RECOMB) 1300 UNITS IV SOLR", "drug_information": { "unit": "1.000000", "type": "F2" }, "code_information": [ { "code": "00944755302_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.0, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 60.06, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "VON WILLEBRAND FACTOR (RECOMB) 1300 UNITS IV SOLR|DISCARDED DRUG NOT ADMINISTERED", "drug_information": { "unit": "1.000000", "type": "F2" }, "code_information": [ { "code": "00944755302", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.35, "maximum": 4.5, "gross_charge": 4.79, "discounted_cash": 2.63, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.78, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.62, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.83, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.06, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.39, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.3, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.87, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.86, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.5, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.22, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.35, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.07, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.59, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.69, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.26, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.5, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.75, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.62, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.81, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.59, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.22, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.78, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.62, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "VON WILLEBRAND FACTOR (RECOMB) 650 UNITS IV SOLR", "drug_information": { "unit": "1.000000", "type": "F2" }, "code_information": [ { "code": "00944755102_2", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.02, "maximum": 103.4, "gross_charge": 110.0, "discounted_cash": 60.5, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.02, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 88.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.17, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.01, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.8, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 65.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.0, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 93.5, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.75, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.8, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.4, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 86.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.38, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 87.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.5, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.8, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 63.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.02, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "VON WILLEBRAND FACTOR (RECOMB) 650 UNITS IV SOLR|DISCARDED DRUG NOT ADMINISTERED", "drug_information": { "unit": "1.000000", "type": "F2" }, "code_information": [ { "code": "00944755102", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.02, "maximum": 4.65, "gross_charge": 4.95, "discounted_cash": 2.72, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.87, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.02, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.96, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.19, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.44, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.38, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.97, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.65, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.36, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.39, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.21, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.71, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.74, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.37, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.65, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.88, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.38, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.94, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.71, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.36, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.87, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.02, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "VORICONAZOLE 200 MG IV SOLR", "drug_information": { "unit": "20.000000", "type": "UN" }, "code_information": [ { "code": "65219019030", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "VORICONAZOLE 200 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687027321", "type": "NDC" } ], "standard_charges": [ { "minimum": 6.29, "maximum": 20.98, "gross_charge": 22.32, "discounted_cash": 12.28, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.95, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.19, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.86, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.91, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.5, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.71, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.37, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.35, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.98, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.64, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.29, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.97, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.74, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.86, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.18, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.98, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.48, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.19, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.74, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.74, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.64, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.95, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.19, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "VORICONAZOLE 40 MG/ML PO SUSR", "drug_information": { "unit": "75.000000", "type": "UN" }, "code_information": [ { "code": "00049316044", "type": "NDC" } ], "standard_charges": [ { "minimum": 271.18, "maximum": 904.59, "gross_charge": 962.33, "discounted_cash": 529.28, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 558.15, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 525.43, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 769.86, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 815.09, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 280.04, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 461.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 576.44, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 575.47, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 904.59, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 846.85, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 271.18, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 817.98, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 721.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 339.03, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 654.38, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 904.59, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 753.5, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 525.43, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 765.05, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 721.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 846.85, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 558.15, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 525.43, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "VORICONAZOLE 50 MG PO TABS", "drug_information": { "unit": "2.000000", "type": "UN" }, "code_information": [ { "code": "60687029421", "type": "NDC" } ], "standard_charges": [ { "minimum": 5.74, "maximum": 19.15, "gross_charge": 20.37, "discounted_cash": 11.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.81, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.12, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.3, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.25, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.93, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9.78, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.2, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.18, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.15, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.93, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.74, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.31, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.28, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.18, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.85, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.15, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.95, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.12, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.19, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15.28, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.93, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.81, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.12, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "VORICONAZOLE INTRAVITREAL INJ (100 MCG/0.05 ML)", "drug_information": { "unit": "0.050000", "type": "UN" }, "code_information": [ { "code": "C0049319056", "type": "NDC" } ], "standard_charges": [ { "minimum": 82.78, "maximum": 276.14, "gross_charge": 293.77, "discounted_cash": 161.57, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 170.39, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 160.4, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 235.02, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 248.82, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 85.49, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 141.01, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 175.97, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 175.67, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 276.14, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 258.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 82.78, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 249.7, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 220.33, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.5, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 199.76, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 276.14, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 230.02, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 160.4, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 233.55, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 220.33, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 258.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 170.39, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 160.4, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "VORICONAZOLE INTRAVITREAL INJ (100 MCG/0.1 ML)", "drug_information": { "unit": "0.100000", "type": "UN" }, "code_information": [ { "code": "C0049319028", "type": "NDC" } ], "standard_charges": [ { "minimum": 103.8, "maximum": 346.26, "gross_charge": 368.36, "discounted_cash": 202.6, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 213.65, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 201.12, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 294.69, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 312.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 107.19, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 176.81, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 220.65, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 220.28, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 346.26, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 324.16, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 103.8, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 313.11, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 276.27, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 129.77, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 250.48, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 346.26, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 288.43, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 201.12, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 292.85, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 276.27, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 324.16, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 213.65, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 201.12, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "VORICONAZOLE OPHTHALMIC SOLN 10 MG/ML", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "08252001800", "type": "NDC" } ], "standard_charges": [ { "minimum": 72.28, "maximum": 241.09, "gross_charge": 256.48, "discounted_cash": 141.06, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 148.76, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 140.04, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 205.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 217.24, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 74.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 123.11, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 153.63, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 153.38, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 241.09, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 225.7, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 72.28, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 218.01, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 192.36, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 90.36, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 174.41, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 241.09, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 200.82, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 140.04, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 203.9, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 192.36, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 225.7, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 148.76, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 140.04, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "VORINOSTAT 100 MG PO CAPS", "drug_information": { "unit": "3.000000", "type": "UN" }, "code_information": [ { "code": "00006056840", "type": "NDC" } ], "standard_charges": [ { "minimum": 370.1, "maximum": 1234.54, "gross_charge": 1313.34, "discounted_cash": 722.34, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 761.74, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 717.08, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1050.67, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1112.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 382.18, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 630.4, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 786.69, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 785.38, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1234.54, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1155.74, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 370.1, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1116.34, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 985.01, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 462.69, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 893.07, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1234.54, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1028.35, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 717.08, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1044.11, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 985.01, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1155.74, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 761.74, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 717.08, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "VORINOSTAT 50 MG/ML SUSPENSION", "drug_information": { "unit": "6.000000", "type": "UN" }, "code_information": [ { "code": "P0006056840", "type": "NDC" } ], "standard_charges": [ { "minimum": 417.24, "maximum": 1391.77, "gross_charge": 1480.61, "discounted_cash": 814.34, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 858.75, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 808.41, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1184.49, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1254.08, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 430.86, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 710.69, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 886.89, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 885.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1391.77, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1302.94, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 417.24, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1258.52, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1110.46, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 521.62, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1006.81, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1391.77, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1159.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 808.41, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 1177.08, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1110.46, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1302.94, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 858.75, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 808.41, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "VORTIOXETINE HBR 10 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "64764073030", "type": "NDC" } ], "standard_charges": [ { "minimum": 10.42, "maximum": 34.74, "gross_charge": 36.96, "discounted_cash": 20.33, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.44, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.57, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.31, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.76, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.74, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.14, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.1, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.74, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.42, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.42, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.72, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.02, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.13, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.74, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.94, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.38, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.72, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.44, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "VORTIOXETINE HBR 20 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "64764075030", "type": "NDC" } ], "standard_charges": [ { "minimum": 10.42, "maximum": 34.74, "gross_charge": 36.96, "discounted_cash": 20.33, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.44, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.57, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.31, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.76, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.74, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.14, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.1, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.74, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 10.42, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.42, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.72, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.02, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 25.13, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.74, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 28.94, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.38, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.72, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.44, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "VUTRISIRAN SODIUM 25 MG/0.5ML SC SOSY", "drug_information": { "unit": "0.500000", "type": "UN" }, "code_information": [ { "code": "71336100301", "type": "NDC" } ], "standard_charges": [ { "minimum": 2689.6, "maximum": 336569.82, "gross_charge": 358053.0, "discounted_cash": 196929.15, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 207670.74, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2689.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 286442.4, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 303270.89, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 104193.42, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 171865.44, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 214473.75, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 11394.0, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": 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"methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 126142.07, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 243476.04, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 336569.82, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 280355.5, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3630.95, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 15189.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 268539.75, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 315086.64, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 207670.74, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2689.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "WARFARIN SODIUM 1 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00832121101", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": 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"standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", 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"payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "WARFARIN SODIUM 10 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00832121901", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "WARFARIN SODIUM 2 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "62584098401", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "WARFARIN SODIUM 2.5 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68084002701", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "WARFARIN SODIUM 3 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00832121401", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "WARFARIN SODIUM 4 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00832121501", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "WARFARIN SODIUM 5 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00832121601", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "WARFARIN SODIUM 6 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00832121701", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "WARFARIN SODIUM 7.5 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00832121801", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "WATER FOR IRRIGATION STERILE IR SOLN", "drug_information": { "unit": "1000.000000", "type": "UN" }, "code_information": [ { "code": "00338000404_3", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "WATER FOR IRRIGATION STERILE IR SOLN 2000ML (BULK CHARGE)", "drug_information": { "unit": "2000.000000", "type": "UN" }, "code_information": [ { "code": "00990797307", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 37.6, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 32.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 33.88, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Waterjet prostate abltj cmpl", "code_information": [ { "code": "0421T", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 6816.07, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5048.94, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 19511.89, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 35404.65, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6816.07, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 35404.65, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "WITCH HAZEL-GLYCERIN EX PADS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "50289325001", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.47, "maximum": 4.89, "gross_charge": 5.2, "discounted_cash": 2.86, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.02, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.16, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.51, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.5, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.11, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.11, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.89, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.58, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.47, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.42, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.9, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.83, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.54, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.89, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.07, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.13, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.9, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.58, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.02, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Wound prep f/n/hf/g", "code_information": [ { "code": "15004", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 451.2, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 334.22, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 10011.76, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 18166.49, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 451.2, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 18166.49, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Wound prep trk/arm/leg", "code_information": [ { "code": "15002", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1348.33, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 9481.64, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 17204.58, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1348.33, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 17204.58, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Wrist arthroscopy", "code_information": [ { "code": "29840", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2391.6, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1771.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 20541.36, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 37272.66, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2391.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 37272.66, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Wrist arthroscopy/surgery", "code_information": [ { "code": "29844", "type": "HCPCS" }, { "code": "29845", "type": "HCPCS" }, { "code": "29846", "type": "HCPCS" }, { "code": "29847", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 5265.64, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1771.56, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3900.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 11033.52, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 20372.4, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2391.6, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5265.64, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 20372.4, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Wrist endoscopy/surgery", "code_information": [ { "code": "29848", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1179.66, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 873.82, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 6960.69, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 12630.28, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1179.66, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 12630.28, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Xcapsl ctrc rmvl cplx w/ecp", "code_information": [ { "code": "66987", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2965.25, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2196.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 11755.13, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 21329.86, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2965.25, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 21329.86, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Xcapsl ctrc rmvl cplx wo ecp", "code_information": [ { "code": "66982", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1681.13, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1245.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 5912.32, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 10727.99, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1681.13, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 10727.99, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Xcapsl ctrc rmvl insj 1+", "code_information": [ { "code": "66991", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 3803.22, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2817.2, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 9164.44, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 16629.04, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3803.22, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 16629.04, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Xcapsl ctrc rmvl w/ecp", "code_information": [ { "code": "66988", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2965.25, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2196.48, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 5853.8, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 10621.81, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2965.25, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 10621.81, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Xcapsl ctrc rmvl w/o ecp", "code_information": [ { "code": "66984", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 1681.13, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 1245.28, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 4957.28, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 8995.06, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 1681.13, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 8995.06, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "Xcpsl ctrc rmvl cplx insj 1+", "code_information": [ { "code": "66989", "type": "HCPCS" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 3803.22, "gross_charge": 0.01, "discounted_cash": 0.01, "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2817.2, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.48, "standard_charge_percentage": 48.0, "estimated_amount": 10020.74, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 18182.8, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3803.22, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "estimated_amount": 18182.8, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "YELLOW FEVER VACCINE SC INJ", "drug_information": { "unit": "0.500000", "type": "UN" }, "code_information": [ { "code": "49281091501", "type": "NDC" } ], "standard_charges": [ { "minimum": 116.77, "maximum": 389.51, "gross_charge": 414.37, "discounted_cash": 227.9, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 240.33, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 226.25, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 331.5, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 350.97, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 120.58, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 198.9, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 248.21, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 247.79, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 389.51, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 364.65, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 116.77, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 352.21, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 310.78, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 145.98, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 281.77, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 389.51, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 324.45, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 226.25, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 329.42, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 310.78, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 364.65, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 240.33, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 226.25, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "YTTRIUM Y-90 IMPLANT", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "08252000201", "type": "NDC" } ], "standard_charges": [ { "minimum": 11394.0, "maximum": 50760.0, "gross_charge": 54000.0, "discounted_cash": 29700.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 31320.0, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 29484.0, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 43200.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 45738.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 15714.0, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 25920.0, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 32346.0, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 11394.0, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 50760.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 47520.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 15217.2, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 45900.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 40500.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 19024.2, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 36720.0, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 50760.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 42282.0, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 29484.0, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 15189.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 40500.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 47520.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31320.0, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 29484.0, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ZAFIRLUKAST 20 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "55111062660", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.15, "maximum": 3.84, "gross_charge": 4.08, "discounted_cash": 2.24, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.37, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.23, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.26, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.46, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.19, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.96, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.44, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.44, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.84, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.59, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.15, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.47, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.06, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.44, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.77, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.84, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.19, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.23, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.24, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.06, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.59, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.37, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.23, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ZALEPLON 5 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "29300013101", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.25, "maximum": 7.52, "gross_charge": 8.0, "discounted_cash": 4.4, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.4, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.78, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.33, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.84, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.79, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.25, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.8, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.82, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.44, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.26, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.36, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ZIDOVUDINE 10 MG/ML IV SOLN", "drug_information": { "unit": "20.000000", "type": "UN" }, "code_information": [ { "code": "49702021326", "type": "NDC" } ], "standard_charges": [ { "minimum": 18.63, "maximum": 62.13, "gross_charge": 66.1, "discounted_cash": 36.36, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.34, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.09, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.88, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 55.99, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.24, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.73, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.59, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.53, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 62.13, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 58.17, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.63, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 56.19, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.58, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.29, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 44.95, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 62.13, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 51.76, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.09, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 52.55, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.58, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 58.17, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.34, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 36.09, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ZIDOVUDINE 100 MG PO CAPS", "drug_information": { "unit": "2.000000", "type": "UN" }, "code_information": [ { "code": "R6586210701", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.93, "maximum": 6.43, "gross_charge": 6.84, "discounted_cash": 3.76, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.97, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.73, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.47, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.79, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.99, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.28, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.1, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.09, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.43, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.02, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.93, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.81, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.13, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.65, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.43, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.36, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.73, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.44, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.13, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.02, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.97, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.73, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ZIDOVUDINE 300 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "65862002460", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ZIDOVUDINE 50 MG/5ML PO SYRP", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "65862004824", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ZINC CHLORIDE 1 MG/ML IV SOLN", "drug_information": { "unit": "10.000000", "type": "UN" }, "code_information": [ { "code": "00409409001", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.27, "maximum": 1158.0, "gross_charge": 40.0, "discounted_cash": 22.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1158.0, "standard_charge_percentage": 100.0, "methodology": "other" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.72, "standard_charge_percentage": 87.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.64, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.2, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.96, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.92, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.27, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.09, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.2, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 37.6, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.32, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 31.8, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 35.2, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 23.2, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 21.84, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ZINC OXIDE 20 % EX OINT", "drug_information": { "unit": "29.000000", "type": "GR" }, "code_information": [ { "code": "75834017001", "type": "NDC" } ], "standard_charges": [ { "minimum": 6.71, "maximum": 22.37, "gross_charge": 23.8, "discounted_cash": 13.09, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.99, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 19.04, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.16, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.93, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 11.42, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.26, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.23, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.37, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.94, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.71, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.23, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.85, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.38, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 16.18, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 22.37, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.64, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.99, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 18.92, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.85, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 20.94, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 13.8, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 12.99, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ZINC OXIDE 40 % EX PSTE", "drug_information": { "unit": "57.000000", "type": "GR" }, "code_information": [ { "code": "74300000070", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.55, "maximum": 8.51, "gross_charge": 9.05, "discounted_cash": 4.98, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.25, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.94, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.24, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.67, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.63, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.34, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.42, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.41, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.51, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.96, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.55, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.69, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.79, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.19, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.15, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 8.51, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.09, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.94, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.19, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.79, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.96, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.25, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.94, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ZINC SULFATE 220 (50 ZN) MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "77333098310", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ZINC SULFATE HEPTAHYDRATE (4.07 MG/ML ELEMENTAL ZINC) ORAL SOLUTION", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "P0904533260", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ZIPRASIDONE HCL 20 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68084010309", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.21, "maximum": 4.05, "gross_charge": 4.31, "discounted_cash": 2.37, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.5, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.35, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.45, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.65, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.25, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.07, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.58, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.58, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.05, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.79, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.21, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.66, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.23, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.52, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.93, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.05, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.37, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.35, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.43, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.23, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.79, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.5, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.35, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ZIPRASIDONE HCL 40 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68084010409", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ZIPRASIDONE HCL 60 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68084010509", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ZIPRASIDONE HCL 80 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68084010609", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ZIV-AFLIBERCEPT 100 MG/4ML IV SOLN", "drug_information": { "unit": "4.000000", "type": "UN" }, "code_information": [ { "code": "00024584001", "type": "NDC" } ], "standard_charges": [ { "minimum": 3.55, "maximum": 4512.0, "gross_charge": 4800.0, "discounted_cash": 2640.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2784.0, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.55, "standard_charge_percentage": 100.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3840.0, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 4065.6, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1396.8, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2304.0, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2875.2, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2870.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", 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total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1691.04, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3264.0, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4512.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3758.4, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", 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"additional_payer_notes": "N/A", "standard_charge_dollar": 3.55, "standard_charge_percentage": 100.0, "methodology": "fee schedule" } ], "additional_generic_notes": "" } ] }, { "description": "ZIV-AFLIBERCEPT 200 MG/8ML IV SOLN", "drug_information": { "unit": "8.000000", "type": "UN" }, "code_information": [ { "code": "00024584101", "type": "NDC" } ], "standard_charges": [ { "minimum": 2705.28, "maximum": 9024.0, "gross_charge": 9600.0, "discounted_cash": 5280.0, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5568.0, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 5241.6, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs 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charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 5740.8, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 9024.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8448.0, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2705.28, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 8160.0, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7200.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 3382.08, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6528.0, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 9024.0, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": 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billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5568.0, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 5241.6, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ZOLEDRONIC ACID 4 MG/5ML IV CONC", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "54288010001", "type": "NDC" } ], "standard_charges": [ { "minimum": 14.36, "maximum": 47.89, "gross_charge": 50.95, "discounted_cash": 28.02, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.55, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.82, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.76, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.15, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.83, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 24.46, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.52, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 30.47, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.89, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 44.84, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 14.36, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 43.31, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.21, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 17.95, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 34.65, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 47.89, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 39.89, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.82, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 40.51, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 38.21, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 44.84, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 29.55, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 27.82, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ZOLEDRONIC ACID 5 MG/100ML IV SOLN", "drug_information": { "unit": "100.000000", "type": "UN" }, "code_information": [ { "code": "67457061910", "type": "NDC" } ], "standard_charges": [ { "minimum": 49.77, "maximum": 166.01, "gross_charge": 176.61, "discounted_cash": 97.14, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 102.43, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.43, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 141.29, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 149.59, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 51.39, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 84.77, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 105.79, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 105.61, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 166.01, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 155.42, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 49.77, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 150.12, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 132.46, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 62.22, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 120.09, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 166.01, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 138.29, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.43, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 140.4, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 132.46, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 155.42, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 102.43, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 96.43, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ZOLPIDEM TARTRATE 5 MG PO TABS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "00904608261", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.25, "maximum": 7.52, "gross_charge": 8.0, "discounted_cash": 4.4, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.4, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.78, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.33, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.84, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.79, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.78, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.25, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.8, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.82, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 5.44, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.52, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.26, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.36, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 6.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 7.04, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.64, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 4.37, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ZONISAMIDE 100 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "60687023001", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ZONISAMIDE 100 MG/5ML PO SUSP", "drug_information": { "unit": "150.000000", "type": "UN" }, "code_information": [ { "code": "52652800101", "type": "NDC" } ], "standard_charges": [ { "minimum": 245.6, "maximum": 819.26, "gross_charge": 871.55, "discounted_cash": 479.35, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 505.5, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 475.87, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 697.24, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 738.2, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 253.62, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 418.34, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 522.06, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 521.19, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 819.26, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 766.96, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 245.6, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 740.82, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 653.66, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 307.05, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 592.65, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 819.26, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 682.42, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 475.87, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 692.88, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 653.66, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 766.96, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 505.5, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 475.87, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ZONISAMIDE 20 MG/ML ORAL SUSPENSION", "drug_information": { "unit": "5.000000", "type": "UN" }, "code_information": [ { "code": "08252000168", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ZONISAMIDE 25 MG PO CAPS", "drug_information": { "unit": "1.000000", "type": "UN" }, "code_information": [ { "code": "68001024200", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.13, "maximum": 3.76, "gross_charge": 4.0, "discounted_cash": 2.2, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.39, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.16, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.92, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.39, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.13, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 1.41, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.72, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.76, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.13, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.18, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 3.52, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.32, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 2.18, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }, { "description": "ZOSTER VAC RECOMB ADJUVANTED 50 MCG/0.5ML IM SUSR", "drug_information": { "unit": "0.500000", "type": "UN" }, "code_information": [ { "code": "58160082311", "type": "NDC" } ], "standard_charges": [ { "minimum": 169.71, "maximum": 566.09, "gross_charge": 602.22, "discounted_cash": 331.22, "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 349.29, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "Medicare Advantage", "additional_payer_notes": "N/A", "standard_charge_dollar": 328.81, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Magellan Human Affairs International", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 481.78, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Health Net", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 510.08, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 175.25, "standard_charge_percentage": 29.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Ship", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 289.07, "standard_charge_percentage": 48.0, "methodology": "percent of total billed charges" }, { "payer_name": "Kaiser", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 360.73, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "EPN", "additional_payer_notes": "N/A", "standard_charge_dollar": 360.13, "standard_charge_percentage": 60.0, "methodology": "percent of total billed charges" }, { "payer_name": "UC Care - PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 566.09, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 529.95, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-City of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 169.71, "standard_charge_percentage": 28.0, "methodology": "percent of total billed charges" }, { "payer_name": "Centivo", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 511.89, "standard_charge_percentage": 85.0, "methodology": "percent of total billed charges" }, { "payer_name": "Private Healthcare System PHC- PPO", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 451.67, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Vivity, Anthem HMO", "plan_name": "HMO-NonCity of LA", "additional_payer_notes": "N/A", "standard_charge_dollar": 212.16, "standard_charge_percentage": 35.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 409.51, "standard_charge_percentage": 68.0, "methodology": "percent of total billed charges" }, { "payer_name": "Anthem Blue Cross", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 566.09, "standard_charge_percentage": 94.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 471.54, "standard_charge_percentage": 78.0, "methodology": "percent of total billed charges" }, { "payer_name": "SCAN", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 328.81, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" }, { "payer_name": "Blue Shield", "plan_name": "All Products", "additional_payer_notes": "N/A", "standard_charge_dollar": 478.76, "standard_charge_percentage": 80.0, "methodology": "percent of total billed charges" }, { "payer_name": "Multiplan", "plan_name": "PPO", "additional_payer_notes": "N/A", "standard_charge_dollar": 451.67, "standard_charge_percentage": 75.0, "methodology": "percent of total billed charges" }, { "payer_name": "Evernorth", "plan_name": "HMO", "additional_payer_notes": "N/A", "standard_charge_dollar": 529.95, "standard_charge_percentage": 88.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 349.29, "standard_charge_percentage": 58.0, "methodology": "percent of total billed charges" }, { "payer_name": "Aetna Medicare", "plan_name": "Medicare", "additional_payer_notes": "N/A", "standard_charge_dollar": 328.81, "standard_charge_percentage": 55.0, "methodology": "percent of total billed charges" } ], "additional_generic_notes": "" } ] }] }